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Individual

ELIA MYA LEXINE

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
LPTA, ATC

Contact information

Practice address
1401 WEST SEMINOLE BLVD, SANFORD, FL 32771
(407) 321-4500
Mailing address
106 NORTH 20TH STREET, FORT PIERCE, FL 34950
(772) 882-2566

Taxonomy

Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA22753
FL
2255A2300X
Athletic Trainer
BOC2000017708

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
PTA2753
STATE LICENSE
FL
Enumeration date
08/06/2014
Last updated
08/06/2014
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