Basic Information
| Provider Information | |||||||||
| NPI: | 1578675906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRERA | ||||||||
| FirstName: | IVELISSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4536 NW WISTERIA DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320554806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867527542 | ||||||||
| FaxNumber: | 3867546450 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867546450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-0013258 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.