Provider Demographics
NPI:1285780783
Name:STUBBINGTON, CHARLEEN AMANDA (PT)
Entity type:Individual
Prefix:MRS
First Name:CHARLEEN
Middle Name:AMANDA
Last Name:STUBBINGTON
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 1:1631 SW 76TH TERR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:30607
Mailing Address - Country:US
Mailing Address - Phone:352-331-2162
Mailing Address - Fax:
Practice Address - Street 1:4820 NEWBERRY ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607
Practice Address - Country:US
Practice Address - Phone:352-373-2116
Practice Address - Fax:352-373-1507
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
106774Medicare ID - Type Unspecified