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NPI Code Detail

MEDICARE: MRS. ANDREA ROSE HEROD PTA

MEDICARE: MRS. ANDREA ROSE HEROD 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
1225200000XPhysical Therapy Assistant

General Provider Information

NPI Number : 1619624715
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ANDREA ROSE HEROD PTA
Provider Business Mailing Address
First Line : 4339 KATIE KIM LN
Second Line :
City : OOLTEWAH
State : TN
Zip : 37363-8454
Country : US
Telephone Number : 423-584-1575
Fax Number :
Provider Business Practice Location Address
First Line : 2745 EXECUTIVE PARK NW
Second Line :
City : CLEVELAND
State : TN
Zip : 37312-2723
Country : US
Telephone Number : 423-584-1575
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/08/2022
Last Update Date : 03/08/2022

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