Healthcare Provider Details

I. General information

NPI: 1124141460
Provider Name (Legal Business Name): NYAWOH WINNIFRED JENGO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NYAWOH WINNIFRED JENGO PTA

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W GIRARD AVE
PHILADELPHIA PA
19130-1400
US

IV. Provider business mailing address

2127 S 58TH ST
PHILADELPHIA PA
19143-5907
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-0800
  • Fax:
Mailing address:
  • Phone: 215-727-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE007796
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: