Healthcare Provider Details

I. General information

NPI: 1275852063
Provider Name (Legal Business Name): MA. IVY PAULINE CRISOSTOMO CUENCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 BERKMAN CIR
SANFORD FL
32771-6311
US

IV. Provider business mailing address

1126 BERKMAN CIR
SANFORD FL
32771-6311
US

V. Phone/Fax

Practice location:
  • Phone: 407-233-8302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: