Healthcare Provider Details

I. General information

NPI: 1629335070
Provider Name (Legal Business Name): MRS. AMY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 JUNIPER SPRING CT
ST AUGUSTINE FL
32092-2451
US

IV. Provider business mailing address

525 JUNIPER SPRING CT
ST AUGUSTINE FL
32092-2451
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-6322
  • Fax:
Mailing address:
  • Phone: 904-940-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: