Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT021642 | PA |
N | 2251G0304X | Physical Therapist - Geriatrics |
NPI | 1083990576 |
---|---|
Provider Name | Deidre Ann Boatright |
First Address | Savannah, GA 31406-6755 |
Second Address | Savannah, GA 31406-6755 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2011 |
Last Update Date | 08/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NA | NA (01) |