Healthcare Provider Details

I. General information

NPI: 1366576779
Provider Name (Legal Business Name): DALE AGNES TUCKER LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
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

2845 COUNTY ROAD 200
OXFORD FL
34484-2309
US

V. Phone/Fax

Practice location:
  • Phone: 352-787-9300
  • Fax:
Mailing address:
  • Phone: 352-748-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 1561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: