Basic Information
| Provider Information | |||||||||
| NPI: | 1033848023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IAGNEMMO | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2230 SW 19TH AVENUE RD | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344711391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522374133 | ||||||||
| FaxNumber: | 3522377728 | ||||||||
| Practice Location | |||||||||
| Address1: | 2135 SW 19TH AVENUE RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344717877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523681340 | ||||||||
| FaxNumber: | 3522377728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA30028 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.