Provider Demographics
NPI:1225649122
Name:WARREN, ELYSE MACKENZIE (DPT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:MACKENZIE
Last Name:WARREN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 2ND ST S APT 306
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6578
Mailing Address - Country:US
Mailing Address - Phone:850-345-0902
Mailing Address - Fax:850-345-0902
Practice Address - Street 1:232 PONTE VEDRA PARK DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-6600
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist