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General NPI Number Information
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NPI Number | 1679755953
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Entity Type | Individual
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Provider Name | CHERYL ELIZABETH WALL LMT
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Gender | Female
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Dates
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Enumeration Date | 11/29/2007
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Last Update Date | 03/31/2010
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Provider Practice Location Address
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Address Line | 4211 U.S. HIGHWAY 1 SOUTH
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-7096
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Country | US
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Telephone | 904-794-0854
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Fax |
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Provider Business Mailing Address
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Address Line | 4211 U.S. HIGHWAY 1 SOUTH
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-7096
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Country | US
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Telephone | 904-794-0854
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA35162
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License Number State | FL
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