Provider Demographics
NPI:1710422605
Name:CONNELLA, MISTY ZHENIA (LMT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:ZHENIA
Last Name:CONNELLA
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:PO BOX 2226
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-2226
Mailing Address - Country:US
Mailing Address - Phone:208-446-6749
Mailing Address - Fax:
Practice Address - Street 1:118 N 7TH ST STE B8
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2704
Practice Address - Country:US
Practice Address - Phone:208-215-4594
Practice Address - Fax:208-561-7752
Is Sole Proprietor?:No
Enumeration Date:2016-12-30
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-891225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist