Provider Demographics
NPI:1215533310
Name:TANNACHION, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:TANNACHION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SE BAYA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6092
Mailing Address - Country:US
Mailing Address - Phone:501-563-4607
Mailing Address - Fax:
Practice Address - Street 1:725 SE BAYA DR STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6092
Practice Address - Country:US
Practice Address - Phone:386-292-6966
Practice Address - Fax:352-218-8312
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA78411225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist