Individual
MRS. STACI DAWN ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
1529 BELMONT ST, BOISE, ID 83725-0001
(208) 426-1459
Mailing address
3612 N SUMMERCREST PL, MERIDIAN, ID 83646-7780
(208) 321-4701
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MASG-217
ID
Other
Enumeration date
06/29/2013
Last updated
06/29/2013
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