Provider Demographics
NPI:1770306029
Name:SANDUSKY, KATELYN MARIE (PTA)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SANDUSKY
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 1:4515 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6092
Mailing Address - Country:US
Mailing Address - Phone:307-635-2388
Mailing Address - Fax:
Practice Address - Street 1:4515 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6092
Practice Address - Country:US
Practice Address - Phone:307-635-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-1157225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant