MEDICARE: NYDIA I VISSEPO

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	225200000X	Physical Therapy Assistant	PTA1901	FL

General Provider Information

NPI Number	:	1750620548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NYDIA I VISSEPO

Provider Business Mailing Address
First Line	:	6663 SPRING GARDEN RUN
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7431
Country	:	US
Telephone Number	:	561-351-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	6663 SPRING GARDEN RUN
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7431
Country	:	US
Telephone Number	:	561-351-9277
Fax Number	:

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

Provider Enumeration Date	:	02/13/2013
Last Update Date	:	02/13/2013

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Directions to “ NYDIA I VISSEPO ” Practice Location

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