Provider Demographics
NPI:1528379005
Name:LEWALLEN, DONNA ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:ANN
Last Name:LEWALLEN
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 1:125 WINSTON MANOR RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-3464
Mailing Address - Country:US
Mailing Address - Phone:850-622-1023
Mailing Address - Fax:
Practice Address - Street 1:125 WINSTON MANOR RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-3464
Practice Address - Country:US
Practice Address - Phone:850-622-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist