Provider Demographics
NPI:1063721751
Name:PENCE, LENNIE GRACE (LMT)
Entity type:Individual
Prefix:MS
First Name:LENNIE
Middle Name:GRACE
Last Name:PENCE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5141 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7844
Mailing Address - Country:US
Mailing Address - Phone:321-259-4853
Mailing Address - Fax:
Practice Address - Street 1:635 S WICKHAM RD
Practice Address - Street 2:SUITE 203
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1436
Practice Address - Country:US
Practice Address - Phone:321-723-1011
Practice Address - Fax:321-723-1110
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23182225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist