Provider Demographics
NPI:1174720262
Name:WAY, KATHLEEN (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB#4015
Mailing Address - Street 2:PO BOX 2430
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513
Mailing Address - Country:US
Mailing Address - Phone:505-693-4771
Mailing Address - Fax:
Practice Address - Street 1:13609 CALIFORNIA STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154
Practice Address - Country:US
Practice Address - Phone:402-891-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA297225200000X
NC3429225200000X
PATE001682L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant