Provider Demographics
NPI:1538160007
Name:MURPHY, PENEMARIE KALLAS (PT)
Entity type:Individual
Prefix:MRS
First Name:PENEMARIE
Middle Name:KALLAS
Last Name:MURPHY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11677
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32239-1677
Mailing Address - Country:US
Mailing Address - Phone:904-744-0277
Mailing Address - Fax:904-744-0263
Practice Address - Street 1:7001 MERRILL RD STE 27
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2600
Practice Address - Country:US
Practice Address - Phone:904-744-0277
Practice Address - Fax:904-744-0263
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0005355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL800295500Medicaid
FLY2843DMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER