MEDICARE: LISHA MYRANDA ESTES LMT

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	MA90239	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA90239	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1306499629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISHA MYRANDA ESTES LMT

Provider Business Mailing Address
First Line	:	10720 HUTCHISON BLVD STE B
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-3708
Country	:	US
Telephone Number	:	850-249-3988
Fax Number	:	850-215-8398

Provider Business Practice Location Address
First Line	:	1829 EDWARDS RD
Second Line	:
City	:	SOUTHPORT
State	:	FL
Zip	:	32409-2403
Country	:	US
Telephone Number	:	850-867-3304
Fax Number	:

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

Provider Enumeration Date	:	07/17/2019
Last Update Date	:	07/17/2019

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