Provider Demographics
NPI:1184383275
Name:CHESTER, AVERY MADISON (PTA)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:MADISON
Last Name:CHESTER
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 1:95-1053 KOOLANI DR APT 24
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-4992
Mailing Address - Country:US
Mailing Address - Phone:281-881-7224
Mailing Address - Fax:
Practice Address - Street 1:1814 LILIHA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2324
Practice Address - Country:US
Practice Address - Phone:281-881-7224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI617225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant