Provider Demographics
NPI:1184024994
Name:CLAYBOURN, TINA MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:CLAYBOURN
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 1:376 N SAMSULA DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8786
Mailing Address - Country:US
Mailing Address - Phone:386-500-8032
Mailing Address - Fax:
Practice Address - Street 1:376 N SAMSULA DR
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8786
Practice Address - Country:US
Practice Address - Phone:386-500-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 54641247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other