MEDICARE: TARA LYNN STURDAVANT 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	MT-25488	AZ

General Provider Information

NPI Number	:	1649919481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA LYNN STURDAVANT LMT

Provider Business Mailing Address
First Line	:	28576 N AMETRINE WAY
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-6020
Country	:	US
Telephone Number	:	616-780-9642
Fax Number	:

Provider Business Practice Location Address
First Line	:	28576 N AMETRINE WAY
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-6020
Country	:	US
Telephone Number	:	616-780-9642
Fax Number	:

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

Provider Enumeration Date	:	05/31/2022
Last Update Date	:	05/31/2022

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