Provider Demographics
NPI:1700305604
Name:DAVIS, KRISERICA DAWN (PTA)
Entity Type:Individual
Prefix:
First Name:KRISERICA
Middle Name:DAWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISERICA
Other - Middle Name:DAWN
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:525 8TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1715
Mailing Address - Country:US
Mailing Address - Phone:850-348-7693
Mailing Address - Fax:
Practice Address - Street 1:626 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6132
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26828225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant