Provider Demographics
NPI:1578378907
Name:DIAZ LOPEZ, JAYMIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JAYMIE
Middle Name:
Last Name:DIAZ LOPEZ
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 1:125 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 S PARK AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4254
Practice Address - Country:US
Practice Address - Phone:407-410-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA33889225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant