Healthcare Provider Details

I. General information

NPI: 1558454983
Provider Name (Legal Business Name): ANGELA GAYLORD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 CRILL AVE STE 3
PALATKA FL
32177-6807
US

IV. Provider business mailing address

148 MILLER SQ
INTERLACHEN FL
32148-4126
US

V. Phone/Fax

Practice location:
  • Phone: 386-325-1119
  • Fax:
Mailing address:
  • Phone: 386-684-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19349
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: