Provider Demographics
NPI:1205300324
Name:PERALTA, AMY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:PERALTA
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 1:912 SW CROSS RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-7532
Mailing Address - Country:US
Mailing Address - Phone:615-613-2056
Mailing Address - Fax:
Practice Address - Street 1:2304 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5316
Practice Address - Country:US
Practice Address - Phone:865-980-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3907225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN62-1632255OtherEMPLOYEER