Healthcare Provider Details

I. General information

NPI: 1821066366
Provider Name (Legal Business Name): MARY LEE PEMENT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5827 HIGHWAY 90
MILTON FL
32583-1763
US

IV. Provider business mailing address

725 VALLEY GRANDE RD
PENSACOLA FL
32514-1576
US

V. Phone/Fax

Practice location:
  • Phone: 850-983-8583
  • Fax: 850-983-8973
Mailing address:
  • Phone: 850-476-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: