Provider Demographics
NPI:1669681672
Name:WETMORE, SHARON ELSA (PTA)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:ELSA
Last Name:WETMORE
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 1:3917 WOODBURN LOOP E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1348
Mailing Address - Country:US
Mailing Address - Phone:863-647-9880
Mailing Address - Fax:
Practice Address - Street 1:4240 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3113
Practice Address - Country:US
Practice Address - Phone:863-607-5948
Practice Address - Fax:863-644-4202
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 15636314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility