Provider Demographics
NPI:1417126285
Name:STANLEY, DONOVAN (PTA)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11947 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7619
Mailing Address - Country:US
Mailing Address - Phone:561-204-2213
Mailing Address - Fax:
Practice Address - Street 1:11947 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-7619
Practice Address - Country:US
Practice Address - Phone:561-204-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA21170OtherFLORIDA MEDICAL LICENSE