Provider Demographics
NPI:1295623833
Name:DAVIS, MARIE ANN (PTA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:ANN
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 8939
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33806-8939
Mailing Address - Country:US
Mailing Address - Phone:863-617-9400
Mailing Address - Fax:863-688-9858
Practice Address - Street 1:PO BOX 8939
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33806-8939
Practice Address - Country:US
Practice Address - Phone:863-617-9400
Practice Address - Fax:863-688-9858
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant