Provider Demographics
NPI:1649488933
Name:EVANS, TINA G (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:G
Last Name:EVANS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BLACK JACK CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6771
Mailing Address - Country:US
Mailing Address - Phone:386-756-0505
Mailing Address - Fax:
Practice Address - Street 1:16 BLACK JACK CIR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6771
Practice Address - Country:US
Practice Address - Phone:386-756-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA34834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA34834OtherMASSAGE LICENSE