Healthcare Provider Details

I. General information

NPI: 1124242722
Provider Name (Legal Business Name): ANNA PUKAJLO-KWASNIEWSKA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 RANCOCAS RD
BURLINGTON NJ
08016-4113
US

IV. Provider business mailing address

888 SPRUCE ST
LAWRENCEVILLE NJ
08648-4530
US

V. Phone/Fax

Practice location:
  • Phone: 609-747-8619
  • Fax:
Mailing address:
  • Phone: 609-393-3707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01233900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: