Healthcare Provider Details

I. General information

NPI: 1811503600
Provider Name (Legal Business Name): KAYLEE FICHTHORN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 S 11TH ST
LAKE WALES FL
33853-4901
US

IV. Provider business mailing address

10455 MANASSAS CIR
ORLANDO FL
32821-8608
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-8502
  • Fax:
Mailing address:
  • Phone: 239-246-0979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT36070
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: