Provider Demographics
NPI:1336633973
Name:LANE, CARISSA (DPT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:LANE
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 1:105 MARINER HEALTH WAY STE 213
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3251
Mailing Address - Country:US
Mailing Address - Phone:904-217-4259
Mailing Address - Fax:904-217-4251
Practice Address - Street 1:105 MARINER HEALTH WAY STE 213
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3251
Practice Address - Country:US
Practice Address - Phone:904-217-4259
Practice Address - Fax:904-217-4251
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36674225100000X
AZ13019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist