Healthcare Provider Details

I. General information

NPI: 1699639633
Provider Name (Legal Business Name): ELIZABETH LOOMIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W 6TH ST
MOSCOW ID
83843-2321
US

IV. Provider business mailing address

317 W 6TH ST
MOSCOW ID
83843-2321
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-3504
  • Fax: 887-935-2107
Mailing address:
  • Phone: 208-882-3504
  • Fax: 877-935-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: