Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MASG-269 | ID |
NPI | 1003394214 |
---|---|
Provider Name | Raeann Thornley |
First Address | Boise, ID 83709-5343 |
Second Address | Boise, ID 83702-4002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2018 |
Last Update Date | 31/07/2018 |