Healthcare Provider Details

I. General information

NPI: 1184804932
Provider Name (Legal Business Name): KATHRYN GISSY WURST LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN S GISSY LMT

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 BLOSSOMWOOD DR
OVIEDO FL
32765
US

IV. Provider business mailing address

2285 BLOSSOMWOOD DR
OVIEDO FL
32765-6455
US

V. Phone/Fax

Practice location:
  • Phone: 407-717-5522
  • Fax:
Mailing address:
  • Phone: 407-717-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 41171
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: