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General NPI Number Information
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NPI Number | 1073121091
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Entity Type | Individual
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Provider Name | MCKINZIE GALE EDSTENE PTA
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Gender | Female
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Dates
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Enumeration Date | 07/15/2020
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Last Update Date | 07/15/2020
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Provider Practice Location Address
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Address Line | 8905 EVERGREEN AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46240-2000
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Country | US
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Telephone | 317-571-1250
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Fax |
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Provider Business Mailing Address
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Address Line | 119 STONEGATE DR
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City | NEW CASTLE
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State | IN
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Zip | 47362-1791
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 06005891A
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License Number State | IN
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