MEDICARE: MISTY WHITE PTA

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	PTA30096	FL

General Provider Information

NPI Number	:	1982293536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY WHITE PTA

Provider Business Mailing Address
First Line	:	2240 SW 70TH AVE STE D
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 SW 70TH AVE STE D
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33317-7112
Country	:	US
Telephone Number	:	855-365-6927
Fax Number	:

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

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	01/18/2021

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Directions to “ MISTY WHITE PTA” Practice Location

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