Provider Demographics
NPI:1740829522
Name:STUTLER, SERINA SHANELL
Entity type:Individual
Prefix:
First Name:SERINA
Middle Name:SHANELL
Last Name:STUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 S WARRINGTON RD STE A3
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1065
Mailing Address - Country:US
Mailing Address - Phone:850-684-0364
Mailing Address - Fax:
Practice Address - Street 1:7 S WARRINGTON RD STE A3
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-1065
Practice Address - Country:US
Practice Address - Phone:850-684-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA65859225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist