MEDICARE: MISS KENYA JEAN WHEATLEY CMT

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	91571	CA

General Provider Information

NPI Number	:	1922839547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KENYA JEAN WHEATLEY CMT

Provider Business Mailing Address
First Line	:	7699 PALMILLA DR APT 3409
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-5098
Country	:	US
Telephone Number	:	909-232-1962
Fax Number	:

Provider Business Practice Location Address
First Line	:	7699 PALMILLA DR APT 3409
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-5098
Country	:	US
Telephone Number	:	909-232-1962
Fax Number	:

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

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	08/13/2024

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