Provider Demographics
NPI:1417107574
Name:NILSSON-GONZALEZ, INDIA DAWN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:INDIA
Middle Name:DAWN
Last Name:NILSSON-GONZALEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:INDIA
Other - Middle Name:DAWN
Other - Last Name:NILSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4448 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1216
Mailing Address - Country:US
Mailing Address - Phone:407-513-3000
Mailing Address - Fax:407-515-6519
Practice Address - Street 1:4448 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-1216
Practice Address - Country:US
Practice Address - Phone:407-513-3000
Practice Address - Fax:407-515-6519
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 18701225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant