Provider Demographics
NPI:1003068560
Name:BAMIDELE, ANNE AJIYI (PTA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:AJIYI
Last Name:BAMIDELE
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 1:3601 W MOORE RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5947
Mailing Address - Country:US
Mailing Address - Phone:765-289-9542
Mailing Address - Fax:
Practice Address - Street 1:2400 CHATEAU DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1900
Practice Address - Country:US
Practice Address - Phone:765-747-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003312A225200000X
IN31005495A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant