Provider Demographics
NPI:1891046785
Name:FERNALD, TAMARA L (LMT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:FERNALD
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 1:603 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1386
Mailing Address - Country:US
Mailing Address - Phone:850-217-0107
Mailing Address - Fax:
Practice Address - Street 1:1796 NAVARRE SOUND CIR.
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566
Practice Address - Country:US
Practice Address - Phone:850-936-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist