Provider Demographics
NPI:1760861124
Name:FISHER, PHOENIX (LMT, CNMT)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HIGHWAY 105 EXT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4297
Mailing Address - Country:US
Mailing Address - Phone:828-406-9993
Mailing Address - Fax:
Practice Address - Street 1:240 HIGHWAY 105 EXT
Practice Address - Street 2:SUITE 200
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4297
Practice Address - Country:US
Practice Address - Phone:828-406-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10634225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist