Provider Demographics
NPI:1881636504
Name:DE PALMA, LISA A (PT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:DE PALMA
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 1:268 WATERS EDGE DR S
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2579
Mailing Address - Country:US
Mailing Address - Phone:904-460-7415
Mailing Address - Fax:732-229-4342
Practice Address - Street 1:4600 MIDDLETON PARK CIR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5691
Practice Address - Country:US
Practice Address - Phone:904-223-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23615208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038199VFCMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #