Provider Demographics
NPI:1407191471
Name:WALLENTINE, KATHRYN LYNETTE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LYNETTE
Last Name:WALLENTINE
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 1:860 W SHERWOOD ST
Mailing Address - Street 2:APT 150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2883
Mailing Address - Country:US
Mailing Address - Phone:208-585-4133
Mailing Address - Fax:
Practice Address - Street 1:860 W SHERWOOD ST
Practice Address - Street 2:APT 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2883
Practice Address - Country:US
Practice Address - Phone:208-585-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2882225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant