Healthcare Provider Details

I. General information

NPI: 1124210331
Provider Name (Legal Business Name): VIVIAN FONTICIELLA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 08/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BISCAYNE BLVD SUITE: 15-A
MIAMI FL
33131-2310
US

IV. Provider business mailing address

1172 S DIXIE HWY #530
CORAL GABLES FL
33146-2918
US

V. Phone/Fax

Practice location:
  • Phone: 305-381-6224
  • Fax: 305-381-6294
Mailing address:
  • Phone: 305-381-6224
  • Fax: 305-381-6294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21912
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: