Provider Demographics
NPI:1639519044
Name:ELLIS, STACI DAWN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:DAWN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 N SUMMERCREST PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7780
Mailing Address - Country:US
Mailing Address - Phone:208-321-4701
Mailing Address - Fax:
Practice Address - Street 1:1529 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0001
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-217174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist