Healthcare Provider Details

I. General information

NPI: 1205013364
Provider Name (Legal Business Name): LAURA JEANNE DENOVI D.O.M, L.A.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA JEANNE POTTER PTA

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date: 05/15/2023
Reactivation Date: 06/05/2023

III. Provider practice location address

116 E BLOOMINGDALE AVE
BRANDON FL
33511-8101
US

IV. Provider business mailing address

3346 STONEBRIDGE TRAIL
VALRICO FL
33596
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-3342
  • Fax: 813-653-0894
Mailing address:
  • Phone: 813-326-7523
  • Fax: 813-653-0894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19090
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP4456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: