Provider Demographics
NPI:1972213510
Name:FEZZIE, MADELINE ELENA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ELENA
Last Name:FEZZIE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11528 WELLMAN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3765
Mailing Address - Country:US
Mailing Address - Phone:863-660-3801
Mailing Address - Fax:
Practice Address - Street 1:1513 SUN CITY CENTER PLZ
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5390
Practice Address - Country:US
Practice Address - Phone:813-634-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT23678225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist