Provider Demographics
NPI:1275047474
Name:ZIEMBA, MARY ROSE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:ZIEMBA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 BRIARVISTA WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3631
Mailing Address - Country:US
Mailing Address - Phone:706-495-2225
Mailing Address - Fax:
Practice Address - Street 1:4516 CHAMBLEE DUNWOODY RD # 22
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:678-459-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 390200000X
GAPT013519225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program