Provider Demographics
NPI:1417013764
Name:INDOE, TANYA L (PT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:INDOE
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:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:COINJOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27923-0093
Mailing Address - Country:US
Mailing Address - Phone:252-267-2401
Mailing Address - Fax:252-453-4143
Practice Address - Street 1:113 EMPERORS ISLE
Practice Address - Street 2:
Practice Address - City:COINJOCK
Practice Address - State:NC
Practice Address - Zip Code:27923-9760
Practice Address - Country:US
Practice Address - Phone:252-267-2401
Practice Address - Fax:252-453-4143
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-2621643OtherTAX ID #