Provider Demographics
NPI:1558443390
Name:PUFKYNEGUS, SANDY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:MARIE
Last Name:PUFKYNEGUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:MARIE
Other - Last Name:PUFKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:937 CABRILLO DR
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-358-0997
Mailing Address - Fax:
Practice Address - Street 1:2107 E. DEL AMO BL
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220
Practice Address - Country:US
Practice Address - Phone:310-637-9611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 1765225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant