Provider Demographics
NPI:1518520592
Name:DELBERT, LEILANI ANN (PTA)
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:ANN
Last Name:DELBERT
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 1:2010 COMMODORE DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7632
Mailing Address - Country:US
Mailing Address - Phone:740-607-4691
Mailing Address - Fax:
Practice Address - Street 1:8888 NAVARRE PKWY
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-3615
Practice Address - Country:US
Practice Address - Phone:850-939-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA009547225200000X
FL27616225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant