=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518502863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI ANN ROAMES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2019
-----------------------------------------------------
Last Update Date | 11/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1477 HUEY ST
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34785-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-251-3902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10540 SE 42ND TER
-----------------------------------------------------
City | BELLEVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34420-6856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-928-1325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PTA26193
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------