Provider Demographics
NPI:1689854283
Name:SMULLEN, MANJARI (LMT)
Entity Type:Individual
Prefix:
First Name:MANJARI
Middle Name:
Last Name:SMULLEN
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 1:11035 NW 60TH DR
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-7456
Mailing Address - Country:US
Mailing Address - Phone:352-222-1829
Mailing Address - Fax:
Practice Address - Street 1:11035 NW 60TH DR
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-7456
Practice Address - Country:US
Practice Address - Phone:352-222-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA51561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist