Healthcare Provider Details

I. General information

NPI: 1568763829
Provider Name (Legal Business Name): ERICA C WALLING PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

V. Phone/Fax

Practice location:
  • Phone: 904-345-7310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number24205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: