Provider Demographics
NPI:1912654104
Name:OQUENDO, LYSETTE (DPT)
Entity Type:Individual
Prefix:MS
First Name:LYSETTE
Middle Name:
Last Name:OQUENDO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3952 JOSLIN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8489
Mailing Address - Country:US
Mailing Address - Phone:321-375-3598
Mailing Address - Fax:
Practice Address - Street 1:3952 JOSLIN WAY
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8489
Practice Address - Country:US
Practice Address - Phone:321-375-3598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047176-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist