Provider Demographics
NPI:1063877694
Name:FENN, MICHELLE (MED, LMT, MLDI)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FENN
Suffix:
Gender:F
Credentials:MED, LMT, MLDI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191072
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1072
Mailing Address - Country:US
Mailing Address - Phone:208-757-2273
Mailing Address - Fax:
Practice Address - Street 1:12071 W FLORIDA DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1157
Practice Address - Country:US
Practice Address - Phone:208-757-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-26
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2422225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist