Healthcare Provider Details

I. General information

NPI: 1861707960
Provider Name (Legal Business Name): MARIAN THOMPSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE B1
SAINT AUGUSTINE FL
32080-7906
US

IV. Provider business mailing address

3793 FLAMINGO ST
ST AUGUSTINE FL
32080-9115
US

V. Phone/Fax

Practice location:
  • Phone: 904-669-4552
  • Fax:
Mailing address:
  • Phone: 904-669-4552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA43810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: