=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720524424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEMENTS OF HEALING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2017
-----------------------------------------------------
Last Update Date | 01/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002B S CHURCH AVE #320253
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33629-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-667-3163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1048 S CLEARVIEW AVE APT 2
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33629-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-748-7256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURE PHYSICIAN
-----------------------------------------------------
Name | DR. LYNN MARTRELL MCPHEARSON
-----------------------------------------------------
Credential | DOM, AP
-----------------------------------------------------
Telephone | 813-748-7256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP3795
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------