Healthcare Provider Details

I. General information

NPI: 1679856801
Provider Name (Legal Business Name): GENNIFER ELIZABETH DEKALANDS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 CRITTENDEN AVE
ORANGE CITY FL
32763-5039
US

IV. Provider business mailing address

885 CRITTENDEN AVE
ORANGE CITY FL
32763-5039
US

V. Phone/Fax

Practice location:
  • Phone: 386-837-8469
  • Fax: 386-218-6776
Mailing address:
  • Phone: 386-837-8469
  • Fax: 386-218-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number20958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: