MEDICARE: JERILYN GANTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT32760	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT32760	OTHER	FL	PT LICENSE NUMBER

General Provider Information

NPI Number	:	1285103598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERILYN GANTT

Provider Business Mailing Address
First Line	:	3657 CORTEZ RD W STE 110
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34210-3171
Country	:	US
Telephone Number	:	941-739-7828
Fax Number	:	941-739-7838

Provider Business Practice Location Address
First Line	:	3657 CORTEZ RD W STE 110
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34210-3171
Country	:	US
Telephone Number	:	941-739-7828
Fax Number	:	941-739-7838

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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Directions to “ JERILYN GANTT ” Practice Location

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