Provider Demographics
NPI:1275643850
Name:PELEN, PATTY
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:PELEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 BOGGY BAYOU CT
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2468
Mailing Address - Country:US
Mailing Address - Phone:850-478-8470
Mailing Address - Fax:
Practice Address - Street 1:554 TWIN CITIES BLVD STE A
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1058
Practice Address - Country:US
Practice Address - Phone:850-729-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT12891OtherLICENSE #