Provider Demographics
NPI:1033507058
Name:CHAN, JOANNA MARIE
Entity Type:Individual
Prefix:
First Name:JOANNA MARIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 PERSIMMON DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-2016
Mailing Address - Country:US
Mailing Address - Phone:903-253-8318
Mailing Address - Fax:
Practice Address - Street 1:5811 PERSIMMON DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-2016
Practice Address - Country:US
Practice Address - Phone:903-253-8318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-27
Last Update Date:2014-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist