Healthcare Provider Details

I. General information

NPI: 1790123255
Provider Name (Legal Business Name): JAMIE WENZELL TELG L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 W NEWBERRY RD
GAINESVILLE FL
32607-2249
US

IV. Provider business mailing address

502 NW 15TH AVE
GAINESVILLE FL
32601-4207
US

V. Phone/Fax

Practice location:
  • Phone: 352-373-2116
  • Fax:
Mailing address:
  • Phone: 352-339-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA69769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: