Provider Demographics
NPI:1265088132
Name:VESTAL, MARILYN ANITA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:ANITA
Last Name:VESTAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 41ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5823
Mailing Address - Country:US
Mailing Address - Phone:863-288-8688
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
05262006OtherT'AI CHI CHIH FOUNDATION