Provider Demographics
NPI:1306197322
Name:CHURCHILL, KATHRYN LIANNE
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LIANNE
Last Name:CHURCHILL
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 1:5252 S ATWOOD TER
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-8108
Mailing Address - Country:US
Mailing Address - Phone:813-760-0925
Mailing Address - Fax:
Practice Address - Street 1:791 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4325
Practice Address - Country:US
Practice Address - Phone:352-364-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62884225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist