Provider Demographics
NPI:1255732137
Name:WAYMIRE, ANGELA (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WAYMIRE
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 1:1773 W GOLDEN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-7228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1773 W GOLDEN HILLS DR
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-7228
Practice Address - Country:US
Practice Address - Phone:765-469-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001645A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant