Provider Demographics
NPI:1932230679
Name:DUNNIVANT, BETH ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:DUNNIVANT
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 1:279 EDWARDS LN
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-3812
Mailing Address - Country:US
Mailing Address - Phone:423-360-8249
Mailing Address - Fax:
Practice Address - Street 1:113 CASSELL DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3775
Practice Address - Country:US
Practice Address - Phone:423-246-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002982225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant