Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 7475 | TN |
NPI | 1003429150 |
---|---|
Provider Name | Mackenna Butler |
First Address | Trenton, TN 38382-9239 |
Second Address | Trenton, TN 38382-2941 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2020 |
Last Update Date | 28/08/2020 |