Provider Demographics
NPI:1316007735
Name:MASSANELLI, SHARON M (LMT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:M
Last Name:MASSANELLI
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:PO BOX 48116
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-8116
Mailing Address - Country:US
Mailing Address - Phone:904-725-1657
Mailing Address - Fax:904-725-7247
Practice Address - Street 1:880 A1A N
Practice Address - Street 2:SUITE 18A
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3220
Practice Address - Country:US
Practice Address - Phone:904-285-2910
Practice Address - Fax:904-285-4663
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA45952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist