Healthcare Provider Details

I. General information

NPI: 1679755953
Provider Name (Legal Business Name): CHERYL ELIZABETH WALL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERYL ELIZABETH HANLEY LMT

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 U.S. HIGHWAY 1 SOUTH
SAINT AUGUSTINE FL
32086-7096
US

IV. Provider business mailing address

4211 U.S. HIGHWAY 1 SOUTH
SAINT AUGUSTINE FL
32086-7096
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-0854
  • Fax:
Mailing address:
  • Phone: 904-794-0854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA35162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: