Provider Demographics
NPI:1265912539
Name:KILLILEA, PENNY (PTA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:KILLILEA
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 1:437 WHITE PATH ST
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-8651
Mailing Address - Country:US
Mailing Address - Phone:740-739-2227
Mailing Address - Fax:
Practice Address - Street 1:417 HILL RD N
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-1310
Practice Address - Country:US
Practice Address - Phone:614-788-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3877225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant