Provider Demographics
NPI:1053900993
Name:CUMMINGS, SALLY ANN
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:CUMMINGS
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 1:3716 RUBIN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-4932
Mailing Address - Country:US
Mailing Address - Phone:321-331-3045
Mailing Address - Fax:
Practice Address - Street 1:48 OSPREY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4955
Practice Address - Country:US
Practice Address - Phone:904-277-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16316224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant