Provider Demographics
NPI:1306181672
Name:MANVEL WALLS, NICOLE RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MANVEL WALLS
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 1:1131 RAILSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8935
Mailing Address - Country:US
Mailing Address - Phone:404-454-3063
Mailing Address - Fax:
Practice Address - Street 1:213 S DILLARD ST STE 110G
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3596
Practice Address - Country:US
Practice Address - Phone:407-877-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 54962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist