Healthcare Provider Details

I. General information

NPI: 1922945781
Provider Name (Legal Business Name): CHANDANIE ETWARU OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 ACAI LN
FORT PIERCE FL
34981-5301
US

IV. Provider business mailing address

434 ACAI LN
FORT PIERCE FL
34981-5301
US

V. Phone/Fax

Practice location:
  • Phone: 863-257-4707
  • Fax:
Mailing address:
  • Phone: 863-257-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA19396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: