Provider Demographics
NPI:1194735654
Name:FEDERICO, RENEE MICHELLE (PT)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:MICHELLE
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8855 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4244
Mailing Address - Country:US
Mailing Address - Phone:904-448-8191
Mailing Address - Fax:904-448-8855
Practice Address - Street 1:8855 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4244
Practice Address - Country:US
Practice Address - Phone:904-448-8191
Practice Address - Fax:904-448-8855
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 23898225100000X
NY018765-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
QP7611Medicare ID - Type Unspecified