Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 26098 | FL |
Y | 2251P0200X | Physical Therapist - Pediatrics | PT26098 | FL |
NPI | 1033307236 |
---|---|
Provider Name | Mrs. Trista Brown |
First Address | Lakeland, FL 33805 |
Second Address | Lakeland, FL 33805 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2007 |
Last Update Date | 19/05/2021 |