Basic Information
| Provider Information | |||||||||
| NPI: | 1770730004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCKWELL | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 158 ROSEMARY ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985848230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604270243 | ||||||||
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| Practice Location | |||||||||
| Address1: | 153 JOHNS CT | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985848225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604272575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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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 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.