Provider Demographics
NPI:1144054115
Name:FUNCHESS, KHYRA JENAI
Entity type:Individual
Prefix:
First Name:KHYRA
Middle Name:JENAI
Last Name:FUNCHESS
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 1:2210 MONACO VISTA DR APT 104
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-5029
Mailing Address - Country:US
Mailing Address - Phone:813-363-1886
Mailing Address - Fax:
Practice Address - Street 1:10726 KETCHUM VALLEY DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-7185
Practice Address - Country:US
Practice Address - Phone:813-819-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA33620225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant