Healthcare Provider Details

I. General information

NPI: 1609193275
Provider Name (Legal Business Name): MARTILENNY JAVIER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

IV. Provider business mailing address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax: 863-455-7049
Mailing address:
  • Phone: 863-679-3338
  • Fax: 863-455-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23209
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: