Provider Demographics
NPI:1457864860
Name:ARDILA, VIVIANA P (PTA)
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:P
Last Name:ARDILA
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 1:20345 MAJESTIC ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32833-3828
Mailing Address - Country:US
Mailing Address - Phone:305-794-5063
Mailing Address - Fax:
Practice Address - Street 1:20345 MAJESTIC ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32833-3828
Practice Address - Country:US
Practice Address - Phone:305-794-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27182225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty