MEDICARE: NESERT ELLAINE PUENARY ASSOCIATE IN SCIENCE

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	225200000X	Physical Therapy Assistant	PTA32602	FL

General Provider Information

NPI Number	:	1811703564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NESERT ELLAINE PUENARY ASSOCIATE IN SCIENCE

Provider Business Mailing Address
First Line	:	198 ARORA BLVD APT 1102
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-3282
Country	:	US
Telephone Number	:	904-510-6241
Fax Number	:

Provider Business Practice Location Address
First Line	:	9560 CROSSHILL BLVD STE 110
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-5827
Country	:	US
Telephone Number	:	904-203-1296
Fax Number	:

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

Provider Enumeration Date	:	12/07/2024
Last Update Date	:	12/07/2024

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