Provider Demographics
NPI:1467744060
Name:WALKER, LORELEI DIANE (LMT)
Entity type:Individual
Prefix:
First Name:LORELEI
Middle Name:DIANE
Last Name:WALKER
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 1:2200 N PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2600
Mailing Address - Country:US
Mailing Address - Phone:904-501-2362
Mailing Address - Fax:
Practice Address - Street 1:2200 N PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2600
Practice Address - Country:US
Practice Address - Phone:904-501-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-15
Last Update Date:2011-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32221225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist