MEDICARE: MRS. CORINNE CARNEVALE NIKITAS MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 20663	FL

General Provider Information

NPI Number	:	1609882455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CORINNE CARNEVALE NIKITAS MPT

Provider Business Mailing Address
First Line	:	3134 W FIELDER ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-2910
Country	:	US
Telephone Number	:	813-835-1652
Fax Number	:

Provider Business Practice Location Address
First Line	:	11930 BOYETTE RD
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-5601
Country	:	US
Telephone Number	:	813-671-1022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	01/06/2010

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