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General NPI Number Information
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NPI Number | 1619187002
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Entity Type | Individual
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Provider Name | MARY LESIE KYZER PTA
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Gender | Female
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 101 HARRIS INDUSTRIAL BLVD
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City | VIDALIA
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State | GA
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Zip | 30474
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Country | US
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Telephone | 912-277-2044
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Fax |
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Provider Business Mailing Address
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Address Line | 104 LAKEVIEW DR
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City | WRIGHTSVILLE
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State | GA
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Zip | 31096-1836
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Country | US
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Telephone | 478-864-2022
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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 | PTA1383
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License Number State | GA
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