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General NPI Number Information
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NPI Number | 1083906366
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Entity Type | Individual
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Provider Name | JOHNNIE L PUCCIO PTA, LMT
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Gender | Female
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Dates
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Enumeration Date | 05/05/2011
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Last Update Date | 05/05/2011
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Provider Practice Location Address
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Address Line | 2129 W NEW HAVEN AVE
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City | W MELBOURNE
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State | FL
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Zip | 32904-3875
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Country | US
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Telephone | 321-723-8299
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Fax |
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Provider Business Mailing Address
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Address Line | 2560 QUARRY AVE SE
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City | PALM BAY
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State | FL
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Zip | 32909-7270
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Country | US
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Telephone | 321-676-4816
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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 | PTA19316
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License Number State | FL
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