Basic Information
| Provider Information | |||||||||
| NPI: | 1740443787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | KYLA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 195 | ||||||||
| Address2: | |||||||||
| City: | MATEWAN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256780195 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 60 PHILLIPS BRANCH RD | ||||||||
| Address2: | |||||||||
| City: | PHELPS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415539061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064568725 | ||||||||
| FaxNumber: | 6064564938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
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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 | A0222 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.