Provider Demographics
NPI:1386841864
Name:PROCTOR, MARLYS K (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARLYS
Middle Name:K
Last Name:PROCTOR
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 1:200 HESTER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-4901
Mailing Address - Country:US
Mailing Address - Phone:615-888-2088
Mailing Address - Fax:
Practice Address - Street 1:200 HESTER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-4901
Practice Address - Country:US
Practice Address - Phone:615-888-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00840225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant