Provider Demographics
NPI:1689713745
Name:SELLE, DONNA J (LAC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:SELLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N COLUMBINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5053
Mailing Address - Country:US
Mailing Address - Phone:208-918-6724
Mailing Address - Fax:
Practice Address - Street 1:3100 N COLUMBINE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5053
Practice Address - Country:US
Practice Address - Phone:208-918-6724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00003028171100000X
WAMA00020240174400000X
ID235ACU171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist