Provider Demographics
NPI:1912593674
Name:GARDNER, MELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GARDNER
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 1:518 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3523
Mailing Address - Country:US
Mailing Address - Phone:208-365-2024
Mailing Address - Fax:208-365-2046
Practice Address - Street 1:518 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3523
Practice Address - Country:US
Practice Address - Phone:208-365-2024
Practice Address - Fax:208-365-2046
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist