Provider Demographics
NPI:1679856801
Name:DEKALANDS, GENNIFER ELIZABETH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:GENNIFER
Middle Name:ELIZABETH
Last Name:DEKALANDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 CRITTENDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-5039
Mailing Address - Country:US
Mailing Address - Phone:386-837-8469
Mailing Address - Fax:386-218-6776
Practice Address - Street 1:885 CRITTENDEN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-5039
Practice Address - Country:US
Practice Address - Phone:386-837-8469
Practice Address - Fax:386-218-6776
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20958225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant