Healthcare Provider Details

I. General information

NPI: 1558086835
Provider Name (Legal Business Name): MARISSA BRYANT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10061 SWEETWATER PKWY
JACKSONVILLE FL
32256-3977
US

IV. Provider business mailing address

3676 BLUE WING CT
ORANGE PARK FL
32065-2518
US

V. Phone/Fax

Practice location:
  • Phone: 904-519-1034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: