Healthcare Provider Details

I. General information

NPI: 1659024560
Provider Name (Legal Business Name): PRIYANKA GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 GRANT LINE RD
NEW ALBANY IN
47150-2492
US

IV. Provider business mailing address

3045 RING RD
ELIZABETHTOWN KY
42701-7933
US

V. Phone/Fax

Practice location:
  • Phone: 812-725-7542
  • Fax: 270-982-0836
Mailing address:
  • Phone: 812-725-7542
  • Fax: 270-982-0836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05014166A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: