Provider Demographics
NPI:1649493362
Name:WEATHERLY, PAMELA B (PT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:B
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:590 441 HISTORIC HWY N
Practice Address - Street 2:STE E
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4561
Practice Address - Country:US
Practice Address - Phone:706-754-6611
Practice Address - Fax:706-754-5834
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116807Medicare ID - Type UnspecifiedGROUP