Provider Demographics
NPI:1083906366
Name:PUCCIO, JOHNNIE L (PTA, LMT)
Entity Type:Individual
Prefix:MRS
First Name:JOHNNIE
Middle Name:L
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 QUARRY AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-7270
Mailing Address - Country:US
Mailing Address - Phone:321-676-4816
Mailing Address - Fax:
Practice Address - Street 1:2129 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3875
Practice Address - Country:US
Practice Address - Phone:321-723-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19316225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant