Provider Demographics
NPI:1114537073
Name:STINNETTE, DARCELLIS (LMT)
Entity Type:Individual
Prefix:
First Name:DARCELLIS
Middle Name:
Last Name:STINNETTE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5164 JOHNSON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-9308
Mailing Address - Country:US
Mailing Address - Phone:717-608-0270
Mailing Address - Fax:
Practice Address - Street 1:1100 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5674
Practice Address - Country:US
Practice Address - Phone:904-551-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA79327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty