Provider Demographics
NPI:1700396694
Name:BARNES, MALISSA H (LMT)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:H
Last Name:BARNES
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 1:2307 CHEROKEE COVE TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-4921
Mailing Address - Country:US
Mailing Address - Phone:904-236-3693
Mailing Address - Fax:
Practice Address - Street 1:1012 MARGARET ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3737
Practice Address - Country:US
Practice Address - Phone:904-236-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL73942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist