=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457161838
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYAH HENNESSEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3715 CRILL AVE
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-9168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-329-2613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 DODGEVILLE ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53543-9722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-929-1271
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------