Provider Demographics
NPI:1821445842
Name:DRAKE, JULIEANN (PTA)
Entity Type:Individual
Prefix:
First Name:JULIEANN
Middle Name:
Last Name:DRAKE
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:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-1609
Mailing Address - Country:US
Mailing Address - Phone:904-277-4449
Mailing Address - Fax:904-277-4177
Practice Address - Street 1:1885 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3033
Practice Address - Country:US
Practice Address - Phone:904-277-4449
Practice Address - Fax:904-277-4177
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26654225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAM305OtherMEDICARE PTAN
FLDO0550OtherRAILROAD MEDICARE
FLY907MOtherBC/BS ID
FLY327QOtherBC/BS ID