Healthcare Provider Details

I. General information

NPI: 1255972998
Provider Name (Legal Business Name): MIRTILA MARIA HISKEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38250 A AVE
ZEPHYRHILLS FL
33542-5759
US

IV. Provider business mailing address

4637 W EASTWIND DR
PLANT CITY FL
33566-1220
US

V. Phone/Fax

Practice location:
  • Phone: 813-782-5508
  • Fax:
Mailing address:
  • Phone: 813-545-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7983
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: