Provider Demographics
NPI:1053455733
Name:BURKE, MANDY MARVIE (LMT)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:MARVIE
Last Name:BURKE
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 1:1501 HASOSAW NENE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5829
Mailing Address - Country:US
Mailing Address - Phone:850-566-4263
Mailing Address - Fax:
Practice Address - Street 1:1278 CEDAR CENTER DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4876
Practice Address - Country:US
Practice Address - Phone:850-224-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA27080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8596OtherBLUE CROSS BLUE SHIELD