=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780954602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENY G SIATKOWSKI PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 01/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6016 ROYAL BIRKDALE DR
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-6523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-601-4997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6016 ROYAL BIRKDALE DR
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-6523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-601-4997
-----------------------------------------------------
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 | 22652
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------