Provider Demographics
NPI:1205991064
Name:SWANN, INNA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:SWANN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8552
Mailing Address - Country:US
Mailing Address - Phone:501-908-5216
Mailing Address - Fax:
Practice Address - Street 1:7 WILLOW BEND DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8552
Practice Address - Country:US
Practice Address - Phone:501-908-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2564225100000X
MS4451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145581721Medicaid
AR5X297OtherBLUE CROSS BLUE SHIELD