Healthcare Provider Details

I. General information

NPI: 1215657077
Provider Name (Legal Business Name): BRIANNA VALLANDINGHAM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD STE 114
ORLANDO FL
32819-4205
US

IV. Provider business mailing address

409 SAINT ANNS DR
WINTER HAVEN FL
33884-3564
US

V. Phone/Fax

Practice location:
  • Phone: 321-732-3723
  • Fax:
Mailing address:
  • Phone: 863-944-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberPTA32163
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA32163
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: