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General NPI Number Information
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NPI Number | 1861683757
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Entity Type | Individual
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Provider Name | KEISHA DIONNE ENGRAM PTA
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Gender | Female
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Dates
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Enumeration Date | 08/06/2007
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Last Update Date | 08/06/2007
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Provider Practice Location Address
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Address Line | 1422 SAN MARCO BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8536
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Country | US
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Telephone | 904-398-4133
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Fax |
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Provider Business Mailing Address
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Address Line | 7601 REED ST
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City | JACKSONVILLE
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State | FL
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Zip | 32208-3720
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Country | US
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Telephone | 904-768-8855
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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 | PTA 20938
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License Number State | FL
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