MEDICARE: TAMMY L PANGBURN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1093958860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY L PANGBURN

Provider Business Mailing Address
First Line	:	1830 NE 21ST ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-4750
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8359 BEACON BLVD
Second Line	:	SUITE 210
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3048
Country	:	US
Telephone Number	:	239-514-4351
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	04/09/2009

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