Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 24638 | FL |
NPI | 1336472299 |
---|---|
Provider Name | Mrs. Carmela Concepcion Canivel Dominise |
First Address | Lakeland, FL 33813 |
Second Address | Lakeland, FL 33813 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2009 |
Last Update Date | 10/09/2009 |