Provider Demographics
NPI:1194506626
Name:SOUKSAVONG, HANNAH (PT, DPT)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:SOUKSAVONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S TWIN MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-8372
Mailing Address - Country:US
Mailing Address - Phone:615-707-9301
Mailing Address - Fax:
Practice Address - Street 1:1305 N ORANGE AVE STE 118
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-2553
Practice Address - Country:US
Practice Address - Phone:904-531-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT39810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist