Provider Demographics
NPI:1386809424
Name:SHOFFSTALL, MARIELLE GRACE (LMT)
Entity type:Individual
Prefix:MISS
First Name:MARIELLE
Middle Name:GRACE
Last Name:SHOFFSTALL
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 1:10218 MISTY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-3300
Mailing Address - Country:US
Mailing Address - Phone:352-617-5121
Mailing Address - Fax:
Practice Address - Street 1:10401 US HIGHWAY 441
Practice Address - Street 2:SUITE 326
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-8787
Practice Address - Country:US
Practice Address - Phone:352-365-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48313225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist