Provider Demographics
NPI:1023045424
Name:BONVILLAIN, TANYA RENOIS (DPT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RENOIS
Last Name:BONVILLAIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HIGHWAY 43 N
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-2126
Mailing Address - Country:US
Mailing Address - Phone:251-679-0015
Mailing Address - Fax:251-679-0091
Practice Address - Street 1:205 HIGHWAY 43 N
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2126
Practice Address - Country:US
Practice Address - Phone:251-679-0015
Practice Address - Fax:251-679-0091
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06643225100000X
ALPTH4836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558048Medicare UPIN