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General NPI Number Information
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NPI Number | 1063877694
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Entity Type | Individual
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Provider Name | MICHELLE FENN M.ED, LMT, MLDI
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Gender | Female
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Dates
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Enumeration Date | 12/26/2015
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Last Update Date | 12/26/2015
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Provider Practice Location Address
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Address Line | 12071 W FLORIDA DR
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City | BOISE
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State | ID
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Zip | 83709-1157
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Country | US
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Telephone | 208-757-2273
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 191072
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City | BOISE
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State | ID
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Zip | 83719-1072
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Country | US
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Telephone | 208-757-2273
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MAS-2422
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License Number State | ID
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