Provider Demographics
NPI:1689795106
Name:DWELLY, PRISCILLA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:DWELLY
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 SW 8TH ST
Mailing Address - Street 2:ZEB 256
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33199-0001
Mailing Address - Country:US
Mailing Address - Phone:305-528-3058
Mailing Address - Fax:
Practice Address - Street 1:11200 SW 8TH ST
Practice Address - Street 2:ZEB 256
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-0001
Practice Address - Country:US
Practice Address - Phone:305-528-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL22112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer