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General NPI Number Information
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NPI Number | 1023674041
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Entity Type | Individual
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Provider Name | ROXANNE NICOLE BULTRON PTA
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Gender | Female
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Dates
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Enumeration Date | 05/15/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 235 W AIRPORT BLVD
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City | PENSACOLA
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State | FL
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Zip | 32505-2239
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Country | US
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Telephone | 850-857-5200
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Fax |
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Provider Business Mailing Address
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Address Line | 8805 MARSH ELDER DR
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City | PENSACOLA
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State | FL
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Zip | 32526-3252
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Country | US
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Telephone | 850-516-9955
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 22805
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License Number State | FL
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