Healthcare Provider Details

I. General information

NPI: 1265056931
Provider Name (Legal Business Name): PAMELA DORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 N WICKHAM RD STE 301
MELBOURNE FL
32940-2240
US

IV. Provider business mailing address

8725 N WICKHAM RD
MELBOURNE FL
32940-2239
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-9200
  • Fax:
Mailing address:
  • Phone: 321-434-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA24761
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA24761
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: