Healthcare Provider Details

I. General information

NPI: 1225107543
Provider Name (Legal Business Name): TIFFANY MARIE LYTLE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY MARIE HANNAKAN PT

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 GOUCHER ST
JOHNSTOWN PA
15905-2942
US

IV. Provider business mailing address

141 SPRUCE CT APT 2
SALIX PA
15952-9439
US

V. Phone/Fax

Practice location:
  • Phone: 814-255-4921
  • Fax: 814-255-4921
Mailing address:
  • Phone: 814-487-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017508
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: