Healthcare Provider Details

I. General information

NPI: 1790365211
Provider Name (Legal Business Name): CHELSEA MALANDRUCCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 EAGLE DR
CRESTVIEW FL
32536-5430
US

IV. Provider business mailing address

114 EAGLE DR
CRESTVIEW FL
32536-5430
US

V. Phone/Fax

Practice location:
  • Phone: 904-210-2602
  • Fax:
Mailing address:
  • Phone: 904-210-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: