Provider Demographics
NPI:1851679088
Name:BAHMANN, VICKY JANE (PT)
Entity Type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:JANE
Last Name:BAHMANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36915 PATTON ROAD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523
Mailing Address - Country:US
Mailing Address - Phone:352-457-6640
Mailing Address - Fax:
Practice Address - Street 1:36915 PATTON RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-1209
Practice Address - Country:US
Practice Address - Phone:352-457-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19646171W00000X
FLFLPT15121208100000X
CACAPT38645208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889589900Medicaid
CAZZZ19896ZMedicare PIN