Healthcare Provider Details

I. General information

NPI: 1558031914
Provider Name (Legal Business Name): KASSARA LYNN LOZANO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HOSPITAL DR
CRESTVIEW FL
32539-7355
US

IV. Provider business mailing address

5925 INDEPENDENCE DR
MILTON FL
32570-3585
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-3146
  • Fax:
Mailing address:
  • Phone: 850-490-2046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number31437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: