Provider Demographics
NPI:1447029640
Name:STODDARD, LORENA (LMT)
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:STODDARD
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 1:1142 OLD FORT GREEN RD
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-7710
Mailing Address - Country:US
Mailing Address - Phone:727-687-7932
Mailing Address - Fax:
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2819
Practice Address - Country:US
Practice Address - Phone:941-779-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA103857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist