Provider Demographics
NPI:1023213857
Name:WYRWA, KIM MICHELE (PTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MICHELE
Last Name:WYRWA
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 1:2035 WISTERIA CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2891
Mailing Address - Country:US
Mailing Address - Phone:770-962-2632
Mailing Address - Fax:
Practice Address - Street 1:3615 BRASELTON HWY
Practice Address - Street 2:STE. 101
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5906
Practice Address - Country:US
Practice Address - Phone:770-904-0772
Practice Address - Fax:770-904-0774
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001703225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant