Healthcare Provider Details

I. General information

NPI: 1497056915
Provider Name (Legal Business Name): DENA SHAE OWENS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 OLD BRANDON RD
BRANDON MS
39042-2543
US

IV. Provider business mailing address

6100 OLD BRANDON RD
BRANDON MS
39042-2543
US

V. Phone/Fax

Practice location:
  • Phone: 601-260-4605
  • Fax: 601-933-1113
Mailing address:
  • Phone: 601-260-4605
  • Fax: 601-933-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2698
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: