Provider Demographics
NPI:1891110722
Name:CHESTNUT, BRANDI (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:CHESTNUT
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 1:5274 N ROLLING ACRES DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47567-8885
Mailing Address - Country:US
Mailing Address - Phone:812-766-9101
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-886-4670
Practice Address - Fax:886-715-9733
Is Sole Proprietor?:No
Enumeration Date:2014-03-01
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004186A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant