Healthcare Provider Details

I. General information

NPI: 1417701848
Provider Name (Legal Business Name): BRIANA HENTHORNE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C 1722 TAGATY ST
FT. LIBERTY NC
28307
US

IV. Provider business mailing address

115 GROVER PL
CAMERON NC
28326-6212
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-6872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA7524
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: