Healthcare Provider Details

I. General information

NPI: 1831406644
Provider Name (Legal Business Name): CRYSTAL LYNN BLANKENSHIP MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W AVON BLVD
AVON PARK FL
33825-8343
US

IV. Provider business mailing address

3400 GARRARD RD
FORT MEADE FL
33841-9534
US

V. Phone/Fax

Practice location:
  • Phone: 863-440-1535
  • Fax:
Mailing address:
  • Phone: 863-440-1535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License NumberMA59595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: