Provider Demographics
NPI:1972089084
Name:TERRANOVA, DONAVAN LEWIS (LMT)
Entity Type:Individual
Prefix:
First Name:DONAVAN
Middle Name:LEWIS
Last Name:TERRANOVA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6735 W 10050 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9211
Mailing Address - Country:US
Mailing Address - Phone:801-669-3963
Mailing Address - Fax:
Practice Address - Street 1:6735 W 10050 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9211
Practice Address - Country:US
Practice Address - Phone:801-669-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10295688-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist