Provider Demographics
NPI:1073639456
Name:BUCK, NOMARA JEANNE (PTA)
Entity Type:Individual
Prefix:
First Name:NOMARA
Middle Name:JEANNE
Last Name:BUCK
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 1:1000 ABADA CT NE
Mailing Address - Street 2:APT 111
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3782
Mailing Address - Country:US
Mailing Address - Phone:321-501-7332
Mailing Address - Fax:
Practice Address - Street 1:490 CENTRE LAKE DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1189
Practice Address - Country:US
Practice Address - Phone:321-768-9776
Practice Address - Fax:321-768-9739
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 14043225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant