Provider Demographics
NPI:1225439193
Name:PONCE, LAILANI (PT)
Entity Type:Individual
Prefix:
First Name:LAILANI
Middle Name:
Last Name:PONCE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W SAINT LOUIS AVE APT G
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2239
Mailing Address - Country:US
Mailing Address - Phone:618-472-4314
Mailing Address - Fax:
Practice Address - Street 1:8369 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4831
Practice Address - Country:US
Practice Address - Phone:240-334-4333
Practice Address - Fax:855-477-7890
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist