Provider Demographics
NPI:1841608163
Name:HEPBURN, NYASUNU WI (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NYASUNU WI
Middle Name:
Last Name:HEPBURN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GLENNVALE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7072
Mailing Address - Country:US
Mailing Address - Phone:940-285-0915
Mailing Address - Fax:
Practice Address - Street 1:1600 BALLEWTOWN RD
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-5337
Practice Address - Country:US
Practice Address - Phone:706-309-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00306700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant