Provider Demographics
NPI:1841520186
Name:HOLLY, IDANIA MILAGROS (LMT)
Entity type:Individual
Prefix:
First Name:IDANIA
Middle Name:MILAGROS
Last Name:HOLLY
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 1:1500 WATERS EDGE DR
Mailing Address - Street 2:U201
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3082
Mailing Address - Country:US
Mailing Address - Phone:813-748-9296
Mailing Address - Fax:
Practice Address - Street 1:1500 WATERS EDGE DR
Practice Address - Street 2:U201
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3082
Practice Address - Country:US
Practice Address - Phone:813-748-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57647225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist