Provider Demographics
NPI:1467817668
Name:ANTRY, KAYLA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:ANTRY
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 1:404 WILLOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-2412
Mailing Address - Country:US
Mailing Address - Phone:618-381-4341
Mailing Address - Fax:
Practice Address - Street 1:2218 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1624
Practice Address - Country:US
Practice Address - Phone:575-746-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007214225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant