Provider Demographics
NPI:1033250238
Name:MALONE, ANNIE (MPT)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1256 W BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-6568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1256 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-6568
Practice Address - Country:US
Practice Address - Phone:630-378-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist