Healthcare Provider Details

I. General information

NPI: 1760037097
Provider Name (Legal Business Name): MICHELLE LEE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LEE JONES

II. Dates (important events)

Enumeration Date: 08/04/2019
Last Update Date: 08/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

359 S LONG BAY WAY
STAR ID
83669-5107
US

V. Phone/Fax

Practice location:
  • Phone: 541-460-0215
  • Fax:
Mailing address:
  • Phone: 541-460-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number57689
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: