Healthcare Provider Details

I. General information

NPI: 1780543140
Provider Name (Legal Business Name): DANEILLIA FORESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2026
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 LEVERICK BAY DR
ST AUGUSTINE FL
32092-3220
US

IV. Provider business mailing address

43 LEVERICK BAY DR
ST AUGUSTINE FL
32092-3220
US

V. Phone/Fax

Practice location:
  • Phone: 904-482-8181
  • Fax:
Mailing address:
  • Phone: 904-482-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number103750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: