Provider Demographics
NPI:1508150004
Name:CUNNINGHAM, ELLEN K (LMT)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:K
Last Name:CUNNINGHAM
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 1:1106 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4542
Mailing Address - Country:US
Mailing Address - Phone:352-792-2016
Mailing Address - Fax:
Practice Address - Street 1:1106 NE 9TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4542
Practice Address - Country:US
Practice Address - Phone:352-792-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 45115225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC3892OtherBLUECROSS BLUESHIELD OF FLORIDA