Healthcare Provider Details

I. General information

NPI: 1457906463
Provider Name (Legal Business Name): SHELLY ANN ZOLEZZI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRONWOOD DR STE 302
COEUR D ALENE ID
83814-4903
US

IV. Provider business mailing address

578 N IDAHO CLUB DR
SANDPOINT ID
83864-5211
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-5225
  • Fax:
Mailing address:
  • Phone: 208-946-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-1921
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: