Provider Demographics
NPI:1558589051
Name:DESANCTIS, DWANA JEANE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DWANA
Middle Name:JEANE
Last Name:DESANCTIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:DWANA
Other - Middle Name:JEANE
Other - Last Name:DESANCTIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3610 WATERFORD CV S
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-8977
Mailing Address - Country:US
Mailing Address - Phone:901-854-9503
Mailing Address - Fax:901-861-8926
Practice Address - Street 1:1500 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0601
Practice Address - Country:US
Practice Address - Phone:901-861-8926
Practice Address - Fax:901-861-8925
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist