Provider Demographics
NPI:1255814950
Name:WINEPOL, ELLIS BARRETT
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:BARRETT
Last Name:WINEPOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-3626
Mailing Address - Country:US
Mailing Address - Phone:772-465-7560
Mailing Address - Fax:
Practice Address - Street 1:700 S 29TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-3626
Practice Address - Country:US
Practice Address - Phone:772-465-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28732225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant