Provider Demographics
NPI:1679989131
Name:BURNS, ANGELA (LMT, MMP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 MOSSY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4772
Mailing Address - Country:US
Mailing Address - Phone:708-204-4562
Mailing Address - Fax:
Practice Address - Street 1:9407 CYPRESS LAKE DR
Practice Address - Street 2:SUITE C
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-0910
Practice Address - Country:US
Practice Address - Phone:239-333-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-05
Last Update Date:2014-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA74523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist