=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205304664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRI-ANN MEGNA PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2018
-----------------------------------------------------
Last Update Date | 11/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 LAKE AVE S
-----------------------------------------------------
City | NESCONSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11767-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-636-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 GEMINI LN
-----------------------------------------------------
City | NESCONSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11767-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-780-6998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 002200-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------