=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699042598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA SWAN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2011
-----------------------------------------------------
Last Update Date | 11/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8840 TERRENE CT UNIT 101
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-9533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-692-1544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27004 ADRIANA CIR #201
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-692-1544
-----------------------------------------------------
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 | 60223
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------