Provider Demographics
NPI:1134884802
Name:TOLBERT, AUDREY PARKER
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:PARKER
Last Name:TOLBERT
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 1:2059 ALTAMONT AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-3281
Mailing Address - Country:US
Mailing Address - Phone:239-400-5639
Mailing Address - Fax:
Practice Address - Street 1:2059 ALTAMONT AVE STE 105
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3281
Practice Address - Country:US
Practice Address - Phone:239-400-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22661225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant