Healthcare Provider Details

I. General information

NPI: 1750534483
Provider Name (Legal Business Name): PENNY M. ELIAS L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2008
Last Update Date: 10/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 W AZEELE ST SUITE A
TAMPA FL
33609-3108
US

IV. Provider business mailing address

2802 W AZEELE ST SUITE A
TAMPA FL
33609-3108
US

V. Phone/Fax

Practice location:
  • Phone: 813-340-6444
  • Fax:
Mailing address:
  • Phone: 813-340-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMA35613
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: