Healthcare Provider Details

I. General information

NPI: 1841608163
Provider Name (Legal Business Name): NYASUNU WI HEPBURN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BALLEWTOWN RD
BLUE RIDGE GA
30513-5337
US

IV. Provider business mailing address

6 GLENNVALE CT
COLUMBIA SC
29223-7072
US

V. Phone/Fax

Practice location:
  • Phone: 706-309-7005
  • Fax:
Mailing address:
  • Phone: 940-285-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00306700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: