=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194506626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNAH SOUKSAVONG PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2023
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 N ORANGE AVE STE 118
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-531-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 S TWIN MAPLE RD
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-8372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-707-9301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT39810
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------