Provider Demographics
NPI:1831464338
Name:MKUTUMULA, ELIZABETH CHIPILIRO
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHIPILIRO
Last Name:MKUTUMULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 TIMBER BAY CIR W
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-4317
Mailing Address - Country:US
Mailing Address - Phone:251-458-9025
Mailing Address - Fax:
Practice Address - Street 1:628 TIMBER BAY CIR W
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-4317
Practice Address - Country:US
Practice Address - Phone:251-458-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA 4585225200000X
FLPTA 22238225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant