Individual
LACEY DELILAH SLADE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
128 5TH AVE W, JEROME, ID 83338-1863
(208) 324-3090
Mailing address
3550 S 2100 E, WENDELL, ID 83355-3529
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA-6147
ID
Other
Enumeration date
05/23/2019
Last updated
05/23/2019
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