Provider Demographics
NPI:1306130026
Name:MARKS, MICHELLE D (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:MARKS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4028
Mailing Address - Country:US
Mailing Address - Phone:208-866-5570
Mailing Address - Fax:
Practice Address - Street 1:1502 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4028
Practice Address - Country:US
Practice Address - Phone:208-866-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist