Provider Demographics
NPI:1134783640
Name:LANKA, PRATHYUSHA BALA (PT)
Entity type:Individual
Prefix:MRS
First Name:PRATHYUSHA
Middle Name:BALA
Last Name:LANKA
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 1:18 BALLO PL
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3837
Mailing Address - Country:US
Mailing Address - Phone:908-217-7153
Mailing Address - Fax:
Practice Address - Street 1:132 EVERGREEN ROAD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-452-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042923225100000X
NJ40QA01854900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist