MEDICARE: MRS. TANIAZEHRA I MOMIN PT

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	31520	FL
2	225100000X	Physical Therapist	PT017463	GA

General Provider Information

NPI Number	:	1306399423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TANIAZEHRA I MOMIN PT

Provider Business Mailing Address
First Line	:	1695 MAIN ST
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-5992
Country	:	US
Telephone Number	:	850-638-3387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1695 MAIN ST
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-5992
Country	:	US
Telephone Number	:	850-638-3387
Fax Number	:

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

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	11/05/2024

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