=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508458308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARON ANN HARTSHORN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2021
-----------------------------------------------------
Last Update Date | 02/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 376 W FOUNTAIN ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02903-3514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-274-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 634 FRUIT HILL AVE
-----------------------------------------------------
City | NORTH PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02911-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-824-9187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT02636
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------