Provider Demographics
NPI:1407618788
Name:NADALA, LANCE GERALD AVELLANA (RPT)
Entity Type:Individual
Prefix:
First Name:LANCE GERALD
Middle Name:AVELLANA
Last Name:NADALA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11801 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3505
Mailing Address - Country:US
Mailing Address - Phone:813-930-8454
Mailing Address - Fax:
Practice Address - Street 1:11801 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3505
Practice Address - Country:US
Practice Address - Phone:813-930-8454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist