Healthcare Provider Details

I. General information

NPI: 1194631614
Provider Name (Legal Business Name): STEPHANIE ALTORFER PRUSIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N 3RD ST
PARMA ID
83660
US

IV. Provider business mailing address

802 N C ST
PARMA ID
83660-5534
US

V. Phone/Fax

Practice location:
  • Phone: 208-515-5044
  • Fax:
Mailing address:
  • Phone: 208-515-5044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA108448
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6881612
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: