Provider Demographics
NPI:1285879791
Name:GILDEMEYER, KATHLEEN (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GILDEMEYER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:FULGINITI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:2500 SUWANEE LAKES TRL
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3161
Mailing Address - Country:US
Mailing Address - Phone:678-377-8210
Mailing Address - Fax:
Practice Address - Street 1:2576 LAWRENCEVILLE SUWANEE RD STE 101
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7291
Practice Address - Country:US
Practice Address - Phone:770-962-4043
Practice Address - Fax:770-962-4045
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001312225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant