Basic Information
| Provider Information | |||||||||
| NPI: | 1669738266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATTANZI | ||||||||
| FirstName: | BRIANNE | ||||||||
| MiddleName: | PETERSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | BRIANNE | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 2813 INDUSTRIAL PARK RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | MIFFLINTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170599078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174366042 | ||||||||
| FaxNumber: | 7174366264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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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 | 225100000X | DAPT003073 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT021931 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1026991420001 | 05 | PA | MEDICAID |