Healthcare Provider Details

I. General information

NPI: 1457264293
Provider Name (Legal Business Name): MARY ANNE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 SHEPHERD RD
ST MARIES ID
83861-9427
US

IV. Provider business mailing address

678 SHEPHERD RD
ST MARIES ID
83861-9427
US

V. Phone/Fax

Practice location:
  • Phone: 208-582-3167
  • Fax:
Mailing address:
  • Phone: 208-582-3167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8881004
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: