Basic Information
| Provider Information | |||||||||
| NPI: | 1669733390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYETTE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DELASALLE | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 PIN OAK DR | ||||||||
| Address2: | |||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391209006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018079277 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 344 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391203551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014432344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2012 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA4741 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.