MEDICARE: SAMANTHA JO FAGNANT LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA63945	FL

General Provider Information

NPI Number	:	1396179578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JO FAGNANT LMT

Provider Business Mailing Address
First Line	:	1312 ILLINOIS AVE
Second Line	:	SUITE E
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4506
Country	:	US
Telephone Number	:	407-436-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	1312 ILLINOIS AVE
Second Line	:	SUITE E
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4506
Country	:	US
Telephone Number	:	407-436-2122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2013
Last Update Date	:	07/07/2014

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