Provider Demographics
NPI:1790304301
Name:MYSIEWICZ, PETRA GODEFRIEDA (PT)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:GODEFRIEDA
Last Name:MYSIEWICZ
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 1:1535 VANN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2095
Mailing Address - Country:US
Mailing Address - Phone:731-984-9962
Mailing Address - Fax:731-984-9941
Practice Address - Street 1:1535 VANN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2095
Practice Address - Country:US
Practice Address - Phone:731-984-9962
Practice Address - Fax:731-984-9941
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2244225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist