Provider Demographics
NPI:1508004243
Name:VEGA, DENISE (LMT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:VEGA
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 1:16387 S TAMIAMI TRL
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5317
Mailing Address - Country:US
Mailing Address - Phone:239-437-0122
Mailing Address - Fax:239-437-0621
Practice Address - Street 1:16387 S TAMIAMI TRL
Practice Address - Street 2:SUITE B
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5317
Practice Address - Country:US
Practice Address - Phone:239-437-0122
Practice Address - Fax:239-437-0621
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA26084225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1988OtherBLUE CROSS BLUE SHIELD