Provider Demographics
NPI:1093309270
Name:KIZILTAN, GLENDA ALICIA (PTA)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:ALICIA
Last Name:KIZILTAN
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 1:5820 W SAMPLE RD APT 205
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3240
Mailing Address - Country:US
Mailing Address - Phone:954-646-4947
Mailing Address - Fax:
Practice Address - Street 1:13550 S JOG RD # 100
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-3808
Practice Address - Country:US
Practice Address - Phone:561-300-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30852225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant