Provider Demographics
NPI:1457374894
Name:PFANNERSTILL, PETE (PHD, LMT, CKTI)
Entity Type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:PFANNERSTILL
Suffix:
Gender:M
Credentials:PHD, LMT, CKTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 W DR MARTIN LUTHER KING JR BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6530
Mailing Address - Country:US
Mailing Address - Phone:813-482-7200
Mailing Address - Fax:
Practice Address - Street 1:1936 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6500
Practice Address - Country:US
Practice Address - Phone:813-875-5872
Practice Address - Fax:813-870-2324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24089225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC0640OtherBLUE CROSS/BLUE SHIELD