=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417829763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICE MIRVIL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2025
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 ROTONDA CIR
-----------------------------------------------------
City | ROTONDA WEST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33947-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-225-5561
-----------------------------------------------------
Fax | 941-460-4494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1116 ROTONDA CIR
-----------------------------------------------------
City | ROTONDA WEST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33947-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-225-5561
-----------------------------------------------------
Fax | 941-460-4494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA28814
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------