Provider Demographics
NPI:1336234673
Name:DAISERNIA, ADRIENNE LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:LEE
Last Name:DAISERNIA
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 1:11605 SAND CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-4547
Mailing Address - Country:US
Mailing Address - Phone:850-532-9051
Mailing Address - Fax:
Practice Address - Street 1:120 N RICHARD JACKSON BLVD
Practice Address - Street 2:SUITE 30
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2521
Practice Address - Country:US
Practice Address - Phone:850-235-6360
Practice Address - Fax:850-235-8871
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist