Provider Demographics
NPI:1932173093
Name:GANA-TAGLE, MITZI MARIE (PT)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:MARIE
Last Name:GANA-TAGLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:MARIE
Other - Last Name:GANA-TAGLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804
Mailing Address - Country:US
Mailing Address - Phone:863-680-7206
Mailing Address - Fax:863-680-7420
Practice Address - Street 1:1430 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-680-7700
Practice Address - Fax:863-680-7958
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6100ZMedicare ID - Type Unspecified