Provider Demographics
NPI:1477759652
Name:PETERNELL, JAMES ANDREW JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ANDREW
Last Name:PETERNELL
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 2ND ST N # C-1
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-3600
Mailing Address - Country:US
Mailing Address - Phone:727-772-3251
Mailing Address - Fax:
Practice Address - Street 1:470 2ND ST N # C-1
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-3600
Practice Address - Country:US
Practice Address - Phone:727-772-3251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 47026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 47026OtherFLORIDA MASSAGE LICENSE #
FLMM 19426OtherMASSAGE ESTABLISHMENT LIC