MEDICARE: LAURA AINLEY PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA003157	GA

General Provider Information

NPI Number	:	1164063855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA AINLEY PTA

Provider Business Mailing Address
First Line	:	151 EAGLE GLEN DR
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-6932
Country	:	US
Telephone Number	:	470-265-7175
Fax Number	:

Provider Business Practice Location Address
First Line	:	4580 TOWNE LAKE PKWY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5521
Country	:	US
Telephone Number	:	770-592-2195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2019
Last Update Date	:	10/03/2019

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