Healthcare Provider Details

I. General information

NPI: 1184553588
Provider Name (Legal Business Name): BANNAPORN BARHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2198 CHASE DR
NICEVILLE FL
32578-1606
US

IV. Provider business mailing address

2198 CHASE DR
NICEVILLE FL
32578-1606
US

V. Phone/Fax

Practice location:
  • Phone: 850-333-8901
  • Fax:
Mailing address:
  • Phone: 850-333-8901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA75344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: