Healthcare Provider Details

I. General information

NPI: 1720058969
Provider Name (Legal Business Name): PATRICIA JEAN KILLEA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 01/09/2008

III. Provider practice location address

MEDICAL SERVICE CORPS STAFF NAVY MEDICINE SUPPORT BLDG 2005
JACKSONVILLE FL
32212-0140
US

IV. Provider business mailing address

4948 34TH ROAD NORTH
ARLINGTON VA
22207
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7200
  • Fax: 904-542-7286
Mailing address:
  • Phone: 973-945-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 13672
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01136300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberEN 31
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: