Provider Demographics
NPI:1851046510
Name:MEREDITH, PHILLIP (RN, LMT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8213
Mailing Address - Country:US
Mailing Address - Phone:615-922-8354
Mailing Address - Fax:
Practice Address - Street 1:1105 7TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1309
Practice Address - Country:US
Practice Address - Phone:615-922-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA92133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist