Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 5129 | ID |
NPI | 1003154568 |
---|---|
Provider Name | Mrs. Christy Jean Ellingford |
First Address | Idaho Falls, ID 83401-5596 |
Second Address | Idaho Falls, ID 83401-5596 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2013 |
Last Update Date | 17/01/2013 |