Healthcare Provider Details

I. General information

NPI: 1265699318
Provider Name (Legal Business Name): TRINA WISE HENKEL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MIDWAY RD
FORT PIERCE FL
34982-4142
US

IV. Provider business mailing address

6800 NW MONOCO CT
PORT ST LUCIE FL
34983-5376
US

V. Phone/Fax

Practice location:
  • Phone: 772-812-9953
  • Fax: 772-871-7842
Mailing address:
  • Phone: 772-812-9953
  • Fax: 772-871-7842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA37838
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: