Provider Demographics
NPI:1104596832
Name:PATARATA, LOVELY ROSE PONCE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:LOVELY ROSE
Middle Name:PONCE
Last Name:PATARATA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:LOVELY ROSE
Other - Middle Name:GOMEZ
Other - Last Name:PONCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:210 S STRAWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-2154
Mailing Address - Country:US
Mailing Address - Phone:334-431-4332
Mailing Address - Fax:
Practice Address - Street 1:210 S STRAWBERRY AVE
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-2154
Practice Address - Country:US
Practice Address - Phone:334-431-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist