Provider Demographics
NPI:1598174328
Name:LEXINE, ELIA MYA (LPTA, ATC)
Entity Type:Individual
Prefix:
First Name:ELIA
Middle Name:MYA
Last Name:LEXINE
Suffix:
Gender:F
Credentials:LPTA, ATC
Other - Prefix:
Other - First Name:ELIA
Other - Middle Name:
Other - Last Name:LEXINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA, ATC
Mailing Address - Street 1:106 NORTH 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950
Mailing Address - Country:US
Mailing Address - Phone:772-882-2566
Mailing Address - Fax:
Practice Address - Street 1:1401 WEST SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771
Practice Address - Country:US
Practice Address - Phone:407-321-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22753225200000X
BOC20000177082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA2753OtherSTATE LICENSE