Provider Demographics
NPI:1679657373
Name:CLYNES, CHARLOTTE SLATTUM (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:SLATTUM
Last Name:CLYNES
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:SLATTUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED MASSAGE THE
Mailing Address - Street 1:5350 SE RUNNING OAK CIR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997
Mailing Address - Country:US
Mailing Address - Phone:772-220-4115
Mailing Address - Fax:772-220-4115
Practice Address - Street 1:1255 THELMA ST
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990
Practice Address - Country:US
Practice Address - Phone:772-220-4115
Practice Address - Fax:772-220-4115
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3266662163W00000X
FLMA4695225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist