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General NPI Number Information
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NPI Number | 1194397893
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Entity Type | Individual
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Provider Name | TAYLOR TUBERTINI MATTINA PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 07/13/2021
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Last Update Date | 10/12/2021
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Provider Practice Location Address
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Address Line | 12449 US 49 SUITE C
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City | GULFPORT
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State | MS
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Zip | 39503-3950
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Country | US
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Telephone | 228-872-6836
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Fax |
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Provider Business Mailing Address
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Address Line | 980 COURTHOUSE RD APT 924
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City | GULFPORT
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State | MS
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Zip | 39507-4288
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Country | US
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Telephone | 228-324-0264
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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 | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | PT-7129
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License Number State | MS
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