Provider Demographics
NPI:1255006037
Name:PENA, MADISON GRACE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:GRACE
Last Name:PENA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5754
Mailing Address - Country:US
Mailing Address - Phone:901-259-1973
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:7580 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5657
Practice Address - Country:US
Practice Address - Phone:901-259-1600
Practice Address - Fax:901-259-1698
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSPTA7197225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant