Provider Demographics
NPI:1346091931
Name:POLANCO, GUADALUPE LIZETH (LMT)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:LIZETH
Last Name:POLANCO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:GUADALUPE
Other - Middle Name:LIZETH
Other - Last Name:ZEPEDA RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:13217 LAKE YALE VIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-8967
Mailing Address - Country:US
Mailing Address - Phone:323-449-2518
Mailing Address - Fax:
Practice Address - Street 1:1416 N DONNELLY ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2814
Practice Address - Country:US
Practice Address - Phone:407-476-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL99859225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist