MEDICARE: MRS. DANA C FUSSELL LPTA

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	2152	TN

General Provider Information

NPI Number	:	1275530495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANA C FUSSELL LPTA

Provider Business Mailing Address
First Line	:	464 TROY POLK STATION RD
Second Line	:
City	:	TROY
State	:	TN
Zip	:	38260-4802
Country	:	US
Telephone Number	:	731-536-5306
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 E REELFOOT AVE
Second Line	:	SUITE 100
City	:	UNION CITY
State	:	TN
Zip	:	38261-6047
Country	:	US
Telephone Number	:	731-884-0744
Fax Number	:

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	07/08/2007

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