Provider Demographics
NPI:1386778207
Name:WHITTAKER, LISA (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25240 ROLLING OAK RD
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-8764
Mailing Address - Country:US
Mailing Address - Phone:352-383-5473
Mailing Address - Fax:352-357-5428
Practice Address - Street 1:25240 ROLLING OAK RD
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-8764
Practice Address - Country:US
Practice Address - Phone:352-383-5473
Practice Address - Fax:352-357-5428
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA937225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant