Provider Demographics
NPI:1801676754
Name:SHOEMAKER, CRYSTAL AMANDA (LMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMANDA
Last Name:SHOEMAKER
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 1:7321 WIREGRASS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32409-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 GRAND PANAMA BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3456
Practice Address - Country:US
Practice Address - Phone:850-276-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90514225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist