Provider Demographics
NPI:1356066401
Name:CHAIYANUT, KETSARIN (MMP)
Entity type:Individual
Prefix:
First Name:KETSARIN
Middle Name:
Last Name:CHAIYANUT
Suffix:
Gender:F
Credentials:MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 3RD ST SE UNIT G
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-7214
Mailing Address - Country:US
Mailing Address - Phone:161-975-3476
Mailing Address - Fax:
Practice Address - Street 1:348 MIRACLE STRIP PKWY SW UNIT 11
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5200
Practice Address - Country:US
Practice Address - Phone:850-716-9959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA98574225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist