Healthcare Provider Details

I. General information

NPI: 1144054115
Provider Name (Legal Business Name): KHYRA JENAI FUNCHESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10726 KETCHUM VALLEY DR
RIVERVIEW FL
33579-7185
US

IV. Provider business mailing address

2210 MONACO VISTA DR APT 104
TAMPA FL
33619-5029
US

V. Phone/Fax

Practice location:
  • Phone: 813-819-1955
  • Fax:
Mailing address:
  • Phone: 813-363-1886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA33620
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: