Healthcare Provider Details

I. General information

NPI: 1598959017
Provider Name (Legal Business Name): ELIZABETH ANNE WENZEL LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8855 SAN JOSE BLVD
JACKSONVILLE FL
32217-4244
US

IV. Provider business mailing address

13072 QUINCY BAY DR
JACKSONVILLE FL
32224-7412
US

V. Phone/Fax

Practice location:
  • Phone: 904-448-8191
  • Fax: 904-448-8855
Mailing address:
  • Phone: 904-992-4550
  • Fax: 904-448-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19066
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: