Provider Demographics
NPI:1538662135
Name:CRUTCHER, ANGIE KAY (PTA)
Entity type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:KAY
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:KAY
Other - Last Name:ASHLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:243 JENNY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-5282
Mailing Address - Country:US
Mailing Address - Phone:863-510-1708
Mailing Address - Fax:
Practice Address - Street 1:243 JENNY WAY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-5282
Practice Address - Country:US
Practice Address - Phone:863-510-1708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24258225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant