Provider Demographics
NPI:1306499629
Name:ESTES, LISHA MYRANDA (LMT)
Entity type:Individual
Prefix:
First Name:LISHA
Middle Name:MYRANDA
Last Name:ESTES
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 1:10720 HUTCHISON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3708
Mailing Address - Country:US
Mailing Address - Phone:850-249-3988
Mailing Address - Fax:850-215-8398
Practice Address - Street 1:1829 EDWARDS RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:FL
Practice Address - Zip Code:32409-2403
Practice Address - Country:US
Practice Address - Phone:850-867-3304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA90239OtherSTATE LICENSE