MEDICARE: MARANDA MACKEY PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	7463	MS

General Provider Information

NPI Number	:	1588497325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARANDA MACKEY PTA

Provider Business Mailing Address
First Line	:	PO BOX 1483
Second Line	:
City	:	FORREST CITY
State	:	AR
Zip	:	72336-1483
Country	:	US
Telephone Number	:	870-270-5117
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 S AVALON ST
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-4170
Country	:	US
Telephone Number	:	870-735-1915
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	08/26/2024

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