Healthcare Provider Details

I. General information

NPI: 1396179578
Provider Name (Legal Business Name): SAMANTHA JO FAGNANT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2013
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 ILLINOIS AVE SUITE E
SAINT CLOUD FL
34769-4506
US

IV. Provider business mailing address

1312 ILLINOIS AVE SUITE E
SAINT CLOUD FL
34769-4506
US

V. Phone/Fax

Practice location:
  • Phone: 407-436-2122
  • Fax:
Mailing address:
  • Phone: 407-436-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA63945
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: