Healthcare Provider Details

I. General information

NPI: 1912654104
Provider Name (Legal Business Name): LYSETTE OQUENDO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 JOSLIN WAY
WEST MELBOURNE FL
32904-8489
US

IV. Provider business mailing address

3952 JOSLIN WAY
WEST MELBOURNE FL
32904-8489
US

V. Phone/Fax

Practice location:
  • Phone: 321-375-3598
  • Fax:
Mailing address:
  • Phone: 321-375-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number047176-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: