Healthcare Provider Details

I. General information

NPI: 1083906366
Provider Name (Legal Business Name): JOHNNIE L PUCCIO PTA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2129 W NEW HAVEN AVE
W MELBOURNE FL
32904-3875
US

IV. Provider business mailing address

2560 QUARRY AVE SE
PALM BAY FL
32909-7270
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-8299
  • Fax:
Mailing address:
  • Phone: 321-676-4816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA19316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: