MEDICARE: KATHLEEN ANN MANNING 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	PTA20050	FL

General Provider Information

NPI Number	:	1962621086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANN MANNING PTA

Provider Business Mailing Address
First Line	:	53 MILLER ST
Second Line	:
City	:	JOHNSTOWN
State	:	NY
Zip	:	12095-1315
Country	:	US
Telephone Number	:	518-844-3595
Fax Number	:

Provider Business Practice Location Address
First Line	:	681 BEVILLE RD
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-1951
Country	:	US
Telephone Number	:	386-756-4395
Fax Number	:

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

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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