Provider Demographics
NPI:1316379332
Name:PROFETTO, HEATHER DIANA (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DIANA
Last Name:PROFETTO
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 1:10746 LIPPIZAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-3657
Mailing Address - Country:US
Mailing Address - Phone:904-993-2741
Mailing Address - Fax:
Practice Address - Street 1:8505 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4225
Practice Address - Country:US
Practice Address - Phone:904-419-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 21452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant