Provider Demographics
NPI:1003584392
Name:MOFFETT, SANDRA MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 SE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6839
Mailing Address - Country:US
Mailing Address - Phone:352-586-6313
Mailing Address - Fax:
Practice Address - Street 1:2717 SE 36TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6839
Practice Address - Country:US
Practice Address - Phone:352-586-6313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant