Provider Demographics
NPI:1093790529
Name:TANKSLEY, PAULA (PT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:TANKSLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 PETALUMA AVE
Mailing Address - Street 2:STE 2G
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4220
Mailing Address - Country:US
Mailing Address - Phone:707-888-5093
Mailing Address - Fax:707-222-6572
Practice Address - Street 1:130 PETALUMA AVE
Practice Address - Street 2:STE 2-G
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4220
Practice Address - Country:US
Practice Address - Phone:707-888-5093
Practice Address - Fax:707-222-6572
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT21613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT216130Medicare ID - Type Unspecified