Healthcare Provider Details

I. General information

NPI: 1144676271
Provider Name (Legal Business Name): KIMBERLY MAFFEO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2016
Last Update Date: 05/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 SARNO RD
MELBOURNE FL
32934-7229
US

IV. Provider business mailing address

431 SHREWSBURY RD
MARY ESTHER FL
32569-1735
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-9200
  • Fax:
Mailing address:
  • Phone: 937-609-3605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number25941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: