Provider Demographics
NPI:1396955241
Name:NEMATOLLAHI, ROYA (LAC)
Entity type:Individual
Prefix:MS
First Name:ROYA
Middle Name:
Last Name:NEMATOLLAHI
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 1:17263 W LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9209
Mailing Address - Country:US
Mailing Address - Phone:208-999-0793
Mailing Address - Fax:208-475-3091
Practice Address - Street 1:1012 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4661
Practice Address - Country:US
Practice Address - Phone:208-999-0793
Practice Address - Fax:208-475-3091
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6100171100000X
IDAC-386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist