Provider Demographics
NPI:1073172821
Name:FIDANZE, ROSALIE MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:MARIE
Last Name:FIDANZE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5744 EVANSTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2808
Mailing Address - Country:US
Mailing Address - Phone:630-536-7949
Mailing Address - Fax:
Practice Address - Street 1:220 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1210
Practice Address - Country:US
Practice Address - Phone:317-776-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN36003480A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer