Provider Demographics
NPI:1144890591
Name:VEHAWN, HOLLY (PTA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:VEHAWN
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 1:118 ROBINWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4364
Mailing Address - Country:US
Mailing Address - Phone:417-349-3009
Mailing Address - Fax:
Practice Address - Street 1:118 ROBINWOOD DR NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4364
Practice Address - Country:US
Practice Address - Phone:417-349-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
FLPTA29344225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant