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1194076109 NPI number — TASHA RENEE DRAKE PT

NPI Number: 1194076109
Health Care Provider/Practitioner: TASHA RENEE DRAKE PT

Information about “1194076109” NPI (TASHA RENEE DRAKE PT) exists in 1194076109 in HTML format HTML  |  1194076109 in plain Text format TXT  |  1194076109 in PDF (Portable Document Format) PDF  |  1194076109 in an XML format XML  formats.

NPI Number : 1194076109 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1194076109",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "DRAKE",
    "FirstName": "TASHA",
    "MiddleName": "RENEE",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "PT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "MIRONENKO",
    "OtherFirstName": "TASHA",
    "OtherMiddleName": "RENEE",
    "OtherNamePrefix": "MISS",
    "OtherNameSuffix": null,
    "OtherCredential": "PT",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "1225 W LAKE ST",
    "SecondLineMailingAddress": "OUTPATIENT PHYSICAL THERAPY",
    "MailingAddressCityName": "MELROSE PARK",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "60160-4039",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "708-938-7262",
    "MailingAddressFaxNumber": "708-938-7955",
    "FirstLinePracticeLocationAddress": "1111 SUPERIOR ST",
    "SecondLinePracticeLocationAddress": "LL",
    "PracticeLocationAddressCityName": "MELROSE PARK",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "60160-4138",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "708-938-7408",
    "PracticeLocationAddressFaxNumber": "708-938-7955",
    "EnumerationDate": "10/01/2012",
    "LastUpdateDate": "10/01/2012",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225100000X",
        "TaxonomyName": "Physical Therapist",
        "LicenseNumber": "070.011252",
        "LicenseNumberStateCode": "IL",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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