Provider Demographics
NPI:1679905723
Name:FITCH, MRKANDA DAS (LMT)
Entity Type:Individual
Prefix:
First Name:MRKANDA
Middle Name:DAS
Last Name:FITCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:FITCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32616-0043
Mailing Address - Country:US
Mailing Address - Phone:352-575-4276
Mailing Address - Fax:
Practice Address - Street 1:1002 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5403
Practice Address - Country:US
Practice Address - Phone:352-575-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA65398225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist