Provider Demographics
NPI:1558454983
Name:GAYLORD, ANGELA (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GAYLORD
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 1:148 MILLER SQ
Mailing Address - Street 2:
Mailing Address - City:INTERLACHEN
Mailing Address - State:FL
Mailing Address - Zip Code:32148-4126
Mailing Address - Country:US
Mailing Address - Phone:386-684-0905
Mailing Address - Fax:
Practice Address - Street 1:6500 CRILL AVE STE 3
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6807
Practice Address - Country:US
Practice Address - Phone:386-325-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19349225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant