Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTAT27624 | FL |
NPI | 1013438258 |
---|---|
Provider Name | Dana Clark |
First Address | Blountstown, FL 32424-9636 |
Second Address | Tallahassee, FL 32308-5304 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2017 |
Last Update Date | 28/06/2017 |