Individual
DIVINE DELA VEGA AUTREY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
470 OLD COUNTRY RD SE, PALM BAY, FL 32909-6906
(561) 201-2240
Mailing address
470 OLD COUNTRY RD SE, PALM BAY, FL 32909-6906
(561) 201-2240
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT31959
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PT31959
PT LICENSE
FL
Enumeration date
07/18/2012
Last updated
11/01/2023
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