Provider Demographics
NPI:1659671907
Name:FISSELL, DEBRA ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:FISSELL
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 1:4406 S. FLORIDA AVE, #16
Mailing Address - Street 2:LEADING EDGE
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:863-648-0099
Mailing Address - Fax:863-688-1824
Practice Address - Street 1:4406 S. FLORIDA AVE, #16
Practice Address - Street 2:LEADING EDGE
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813
Practice Address - Country:US
Practice Address - Phone:863-648-0099
Practice Address - Fax:863-688-1824
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA17274225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant