Provider Demographics
NPI:1932342342
Name:RONQUILLO, MARICEL RIVERA
Entity Type:Individual
Prefix:
First Name:MARICEL
Middle Name:RIVERA
Last Name:RONQUILLO
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 1:260 1ST AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4364
Mailing Address - Country:US
Mailing Address - Phone:727-308-9848
Mailing Address - Fax:727-502-6027
Practice Address - Street 1:433 ORANGE DR
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5377
Practice Address - Country:US
Practice Address - Phone:407-576-5712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009221225100000X
FLPT29085261QP2000X
FLPT29087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy