Provider Demographics
NPI:1669609855
Name:LEGERSKI, VICKI LYNN (PTA)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:LEGERSKI
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:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1790
Mailing Address - Country:US
Mailing Address - Phone:307-358-9434
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:360 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2719
Practice Address - Country:US
Practice Address - Phone:307-746-3573
Practice Address - Fax:307-746-3572
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-357225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant