Provider Demographics
NPI:1518118611
Name:MANNIKKO, STEPHANIE MICHELE (DPT, MCMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELE
Last Name:MANNIKKO
Suffix:
Gender:F
Credentials:DPT, MCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SE 4TH CT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-8013
Mailing Address - Country:US
Mailing Address - Phone:732-406-0312
Mailing Address - Fax:
Practice Address - Street 1:3325 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6999
Practice Address - Country:US
Practice Address - Phone:954-986-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 25244225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2384Medicaid
SC426586Medicare UPIN