Provider Demographics
NPI:1750620548
Name:VISSEPO, NYDIA I
Entity type:Individual
Prefix:
First Name:NYDIA
Middle Name:I
Last Name:VISSEPO
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 1:6663 SPRING GARDEN RUN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7431
Mailing Address - Country:US
Mailing Address - Phone:561-351-9277
Mailing Address - Fax:
Practice Address - Street 1:6663 SPRING GARDEN RUN
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7431
Practice Address - Country:US
Practice Address - Phone:561-351-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA1901225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant