Provider Demographics
NPI:1780818252
Name:ELLIS, LONI
Entity Type:Individual
Prefix:
First Name:LONI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 N STOKESBERRY PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1144
Mailing Address - Country:US
Mailing Address - Phone:208-373-7733
Mailing Address - Fax:208-373-7755
Practice Address - Street 1:2524 N STOKESBERRY PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1144
Practice Address - Country:US
Practice Address - Phone:208-373-7733
Practice Address - Fax:208-373-7755
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist