Provider Demographics
NPI:1699284380
Name:PODVIN, AMY JANAE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JANAE
Last Name:PODVIN
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 1:583 MENDOZA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7939
Mailing Address - Country:US
Mailing Address - Phone:386-972-8698
Mailing Address - Fax:
Practice Address - Street 1:250 S CHICKASAW TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3503
Practice Address - Country:US
Practice Address - Phone:407-380-3466
Practice Address - Fax:321-418-3297
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant