MEDICARE: LONI ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1780818252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LONI ELLIS

Provider Business Mailing Address
First Line	:	2524 N STOKESBERRY PL
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1144
Country	:	US
Telephone Number	:	208-373-7733
Fax Number	:	208-373-7755

Provider Business Practice Location Address
First Line	:	2524 N STOKESBERRY PL
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1144
Country	:	US
Telephone Number	:	208-373-7733
Fax Number	:	208-373-7755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	05/12/2009

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Directions to “ LONI ELLIS ” Practice Location

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