Individual
LACEY MEGORDEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
BS
Contact information
Practice address
4222 W EMERALD ST, BOISE, ID 83706-2037
(208) 605-3663
(208) 605-3663
Mailing address
4222 W EMERALD ST, BOISE, ID 83706-2037
(208) 605-3663
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1
—
ID
Enumeration date
04/07/2019
Last updated
04/07/2019
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