Provider Demographics
NPI:1699030361
Name:LEWIS, PAMELA BROWN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:BROWN
Last Name:LEWIS
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 1:2 GREENVALE DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8780
Mailing Address - Country:US
Mailing Address - Phone:386-295-7540
Mailing Address - Fax:
Practice Address - Street 1:3001 PALM COAST PKWY SE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8209
Practice Address - Country:US
Practice Address - Phone:386-446-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 10843225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant