MEDICARE: MISS AMY LAVERNE MIDDLETON 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	34273	FL
2	225200000X	Physical Therapy Assistant	003303	GA

General Provider Information

NPI Number	:	1275926602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMY LAVERNE MIDDLETON PTA

Provider Business Mailing Address
First Line	:	3330 KIMBERLY RD NW
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30144-1144
Country	:	US
Telephone Number	:	404-281-1012
Fax Number	:

Provider Business Practice Location Address
First Line	:	4795 FULTON INDUSTRIAL BLVD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30336-2000
Country	:	US
Telephone Number	:	404-267-5700
Fax Number	:

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

Provider Enumeration Date	:	03/10/2015
Last Update Date	:	05/21/2026

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