Healthcare Provider Details

I. General information

NPI: 1083182141
Provider Name (Legal Business Name): TONYO LORENZO SYLVESTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 NORTH PAVILLION PLACE
PENNEY FARMS FL
32079
US

IV. Provider business mailing address

192 HERITAGE OAKS DR
SAINT JOHNS FL
32259-2223
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-3897
  • Fax:
Mailing address:
  • Phone: 301-437-5175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA16797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: