Healthcare Provider Details

I. General information

NPI: 1487978987
Provider Name (Legal Business Name): FRITZELLYN CANON DUBOSE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FRITZELLYN CANON QUIAO PT

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 TROPICAL CT
TAVARES FL
32778-4340
US

IV. Provider business mailing address

15630 SE 93RD AVE
SUMMERFIELD FL
34491-5621
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-9856
  • Fax:
Mailing address:
  • Phone: 321-362-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25047
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: