Basic Information
| Provider Information | |||||||||
| NPI: | 1023256633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINNIE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | AUDREY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WINNIE | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | AUDREY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8455 S SUNCOAST BLVD | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344465066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524655880 | ||||||||
| FaxNumber: | 3524655889 | ||||||||
| Practice Location | |||||||||
| Address1: | 20726 W PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | DUNNELLON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344316717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524655880 | ||||||||
| FaxNumber: | 3524655889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 02/04/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA21570 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 106898 | 01 | FL | MEDICARE ID | OTHER |