Healthcare Provider Details

I. General information

NPI: 1043570583
Provider Name (Legal Business Name): DIANA FOGLE BIANCHET LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 GUNN HWY
TAMPA FL
33625-4105
US

IV. Provider business mailing address

3037 CLOVER BLOSSOM CIR
LAND O LAKES FL
34638-7985
US

V. Phone/Fax

Practice location:
  • Phone: 813-864-3998
  • Fax: 813-864-3141
Mailing address:
  • Phone: 703-220-9864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 52905
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: