Provider Demographics
NPI:1023345550
Name:PROVOST-HUNTER, RENEE MARIE
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:MARIE
Last Name:PROVOST-HUNTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:MARIE
Other - Last Name:PROVOST-HUNTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:123 PELICAN ISLAND PL
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6965
Mailing Address - Country:US
Mailing Address - Phone:772-713-7720
Mailing Address - Fax:
Practice Address - Street 1:512 COMMERCE CENTER 709G
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-6965
Practice Address - Country:US
Practice Address - Phone:772-713-7720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA49153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist