Healthcare Provider Details

I. General information

NPI: 1619216298
Provider Name (Legal Business Name): MRS. MAGDALENA IWANEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2013
Last Update Date: 02/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W LAKE PARKER DR
LAKELAND FL
33805-5005
US

IV. Provider business mailing address

5412 RIVER ROCK RD
LAKELAND FL
33809-0960
US

V. Phone/Fax

Practice location:
  • Phone: 863-603-6811
  • Fax:
Mailing address:
  • Phone: 863-608-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 12969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: