Provider Demographics
NPI:1598940744
Name:PATRICK, MANDY ANISSA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:ANISSA
Last Name:PATRICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8040 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1773
Mailing Address - Country:US
Mailing Address - Phone:901-522-6440
Mailing Address - Fax:901-757-2507
Practice Address - Street 1:8040 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1773
Practice Address - Country:US
Practice Address - Phone:901-522-6440
Practice Address - Fax:901-757-2507
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3360225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant