Provider Demographics
NPI:1265830657
Name:CORDER, ILA (PTA)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:CORDER
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 1:368 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-7481
Mailing Address - Country:US
Mailing Address - Phone:606-549-0886
Mailing Address - Fax:606-549-2665
Practice Address - Street 1:368 PENNY LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-7481
Practice Address - Country:US
Practice Address - Phone:606-549-0886
Practice Address - Fax:606-549-2665
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAO1314225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6063761318Medicare NSC