Provider Demographics
NPI:1306399423
Name:MOMIN, TANIAZEHRA I (PT)
Entity Type:Individual
Prefix:MRS
First Name:TANIAZEHRA
Middle Name:I
Last Name:MOMIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-5992
Mailing Address - Country:US
Mailing Address - Phone:850-638-3387
Mailing Address - Fax:
Practice Address - Street 1:1695 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-5992
Practice Address - Country:US
Practice Address - Phone:850-638-3387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist