Healthcare Provider Details

I. General information

NPI: 1053663005
Provider Name (Legal Business Name): KERI PETYS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 VONDERBURG DR SUITE 201
BRANDON FL
33511-5900
US

IV. Provider business mailing address

5540 ANTELOPE LN
NEW PORT RICHEY FL
34653-4518
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-1149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: