Provider Demographics
NPI:1700500923
Name:PONA, ANASTASIA
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:PONA
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 1:4245 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4510
Mailing Address - Country:US
Mailing Address - Phone:609-661-1442
Mailing Address - Fax:
Practice Address - Street 1:243 HOLLYWOOD BLVD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4725
Practice Address - Country:US
Practice Address - Phone:850-852-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22697225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist