Provider Demographics
NPI:1144532243
Name:LANTZ, ANDREA NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:LANTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 LISA CT
Mailing Address - Street 2:#622
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1283
Mailing Address - Country:US
Mailing Address - Phone:304-838-4046
Mailing Address - Fax:
Practice Address - Street 1:1 SUTPHIN DR
Practice Address - Street 2:
Practice Address - City:MARMET
Practice Address - State:WV
Practice Address - Zip Code:25315-1977
Practice Address - Country:US
Practice Address - Phone:304-949-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001571225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant