Provider Demographics
NPI:1528737939
Name:TARAVELLA, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:TARAVELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10851 S OCEAN DR LOT 64
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-2642
Mailing Address - Country:US
Mailing Address - Phone:305-849-6877
Mailing Address - Fax:
Practice Address - Street 1:10851 S OCEAN DR LOT 64
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-2642
Practice Address - Country:US
Practice Address - Phone:305-849-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL378382225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist