Provider Demographics
NPI:1578675906
Name:HERRERA, IVELISSE (PT)
Entity Type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:
Last Name:HERRERA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 NW WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4806
Mailing Address - Country:US
Mailing Address - Phone:386-752-7542
Mailing Address - Fax:386-754-6450
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-754-6450
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT-0013258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist