Provider Demographics
NPI:1134701766
Name:ETIENNE, FAYOLA O (DPT)
Entity Type:Individual
Prefix:
First Name:FAYOLA
Middle Name:O
Last Name:ETIENNE
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 1:4 HART DR N
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1534
Mailing Address - Country:US
Mailing Address - Phone:862-371-8510
Mailing Address - Fax:
Practice Address - Street 1:1145 19TH ST NW STE 403
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-3716
Practice Address - Country:US
Practice Address - Phone:202-721-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist