Provider Demographics
NPI:1265601082
Name:SUMMERLIN, KATHARINE FANNON (LMT)
Entity type:Individual
Prefix:MS
First Name:KATHARINE
Middle Name:FANNON
Last Name:SUMMERLIN
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 1:1506 TWIN LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-4195
Mailing Address - Country:US
Mailing Address - Phone:850-508-4612
Mailing Address - Fax:850-656-5589
Practice Address - Street 1:1304 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6506
Practice Address - Country:US
Practice Address - Phone:850-508-4612
Practice Address - Fax:850-656-5589
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40605225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC3746OtherBLUECROSS / BLUESHIELD