1477237113 NPI number — DR. MIKAYLA PATRICIA PETERSEN PT, DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477237113 NPI number — DR. MIKAYLA PATRICIA PETERSEN PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
MIKAYLA
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCMANIMON GARLAND
Provider Other First Name:
MIKAYLA
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477237113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1173 ROCK SPRINGS RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37167-8414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-220-5796
Provider Business Mailing Address Fax Number:
615-220-8829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
388 HARDING PL STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37211-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-220-5796
Provider Business Practice Location Address Fax Number:
615-220-8829
Provider Enumeration Date:
06/13/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  LPT32960 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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