Healthcare Provider Details

I. General information

NPI: 1417117151
Provider Name (Legal Business Name): TABATHA JOLANE EADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N 12TH AVE
PENSACOLA FL
32503-4717
US

IV. Provider business mailing address

5212 VICTORIA DR
MILTON FL
32570-6870
US

V. Phone/Fax

Practice location:
  • Phone: 850-432-6870
  • Fax:
Mailing address:
  • Phone: 850-261-8722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number53349
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: