Individual
TRACY JO ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
157 W HAYDEN AVE, HAYDEN LAKE, ID 83835-9650
(509) 216-3663
Mailing address
1628 W JUDY K DR, RATHDRUM, ID 83858-7502
(509) 216-3663
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
MAS-1492
ID
Other
Enumeration date
03/19/2015
Last updated
03/19/2015
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