Provider Demographics
NPI:1053178335
Name:JAISWAL, PRIYANKA
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:JAISWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 PROCTOR DR UNIT 11107
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4139
Mailing Address - Country:US
Mailing Address - Phone:704-307-5059
Mailing Address - Fax:
Practice Address - Street 1:760 BARNES BLVD STE 103
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5314
Practice Address - Country:US
Practice Address - Phone:321-327-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist