Provider Demographics
NPI:1245561166
Name:AVENDANO, MARY GREANNE GARCIA
Entity Type:Individual
Prefix:
First Name:MARY GREANNE
Middle Name:GARCIA
Last Name:AVENDANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 TAMIAMI TRL STE A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9255
Mailing Address - Country:US
Mailing Address - Phone:941-766-1110
Mailing Address - Fax:941-766-1190
Practice Address - Street 1:4166 TAMIAMI TRL STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9255
Practice Address - Country:US
Practice Address - Phone:941-766-1110
Practice Address - Fax:941-766-1190
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist