Provider Demographics
NPI:1487978987
Name:DUBOSE, FRITZELLYN CANON (PT)
Entity type:Individual
Prefix:
First Name:FRITZELLYN
Middle Name:CANON
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:FRITZELLYN
Other - Middle Name:CANON
Other - Last Name:QUIAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:15630 SE 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-5621
Mailing Address - Country:US
Mailing Address - Phone:321-362-0232
Mailing Address - Fax:
Practice Address - Street 1:1599 TROPICAL CT
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4340
Practice Address - Country:US
Practice Address - Phone:352-742-9856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist