Provider Demographics
NPI:1568609527
Name:COLEMAN, PETREA ANN (PT)
Entity Type:Individual
Prefix:
First Name:PETREA
Middle Name:ANN
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4562 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3618
Mailing Address - Country:US
Mailing Address - Phone:770-806-4136
Mailing Address - Fax:770-806-4139
Practice Address - Street 1:4562 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 201
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3618
Practice Address - Country:US
Practice Address - Phone:770-806-4136
Practice Address - Fax:770-806-4139
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I650346Medicare PIN