Provider Demographics
NPI:1669611042
Name:STORES, PATRICIA S (RN, LMT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:S
Last Name:STORES
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3548 BESSENT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-5016
Mailing Address - Country:US
Mailing Address - Phone:904-768-7293
Mailing Address - Fax:
Practice Address - Street 1:1437 FLAGLER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8516
Practice Address - Country:US
Practice Address - Phone:904-768-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35735225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist