Provider Demographics
NPI:1790121465
Name:ALFONSO, NATALIE (PTA)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:ALFONSO
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 1:14401 LAKE CRESCENT PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3036
Mailing Address - Country:US
Mailing Address - Phone:305-496-8605
Mailing Address - Fax:
Practice Address - Street 1:14401 LAKE CRESCENT PL
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-3036
Practice Address - Country:US
Practice Address - Phone:305-495-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22509225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant