Healthcare Provider Details

I. General information

NPI: 1427040872
Provider Name (Legal Business Name): NANCY ANN MARIN OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 PALM VALLEY RD
PONTE VEDRA BEACH FL
32082-3200
US

IV. Provider business mailing address

100 BOUGANVILLA DR
PONTE VEDRA BEACH FL
32082-3676
US

V. Phone/Fax

Practice location:
  • Phone: 904-382-9790
  • Fax:
Mailing address:
  • Phone: 904-280-5336
  • Fax: 904-373-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: