Healthcare Provider Details

I. General information

NPI: 1679110845
Provider Name (Legal Business Name): ANGELA ALICE CHAPIN MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA ALICE CHAPIN

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200
PONDERAY ID
83852-5005
US

IV. Provider business mailing address

43 SANDY BEACH LN
COCOLALLA ID
83813-8705
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-9559
  • Fax:
Mailing address:
  • Phone: 208-659-2603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS3548
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: