Healthcare Provider Details

I. General information

NPI: 1104293620
Provider Name (Legal Business Name): JOANN FICOCELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W NORTH BLVD SUITE D
LEESBURG FL
34748-5063
US

IV. Provider business mailing address

600 W NORTH BLVD SUITE D
LEESBURG FL
34748-5063
US

V. Phone/Fax

Practice location:
  • Phone: 352-728-6636
  • Fax: 352-787-4522
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA17297
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: