Provider Demographics
NPI:1679984470
Name:WIETNIK, PATRICIA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:WIETNIK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:MARIE
Other - Last Name:WIETNIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:6700 ANTIOCH RD
Mailing Address - Street 2:SUITE #120
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1497
Mailing Address - Country:US
Mailing Address - Phone:913-652-9229
Mailing Address - Fax:888-652-9198
Practice Address - Street 1:6700 ANTIOCH RD
Practice Address - Street 2:SUITE #120
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-1497
Practice Address - Country:US
Practice Address - Phone:913-652-9229
Practice Address - Fax:888-652-9198
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01818225200000X
MO2006015594225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant