Provider Demographics
NPI:1427601954
Name:BANCILA, ANA CORINA (PTA, CKTP)
Entity Type:Individual
Prefix:
First Name:ANA CORINA
Middle Name:
Last Name:BANCILA
Suffix:
Gender:F
Credentials:PTA, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4571 S WOODDUCK LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4116
Mailing Address - Country:US
Mailing Address - Phone:706-816-2827
Mailing Address - Fax:
Practice Address - Street 1:12702 S FORT ST
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9755
Practice Address - Country:US
Practice Address - Phone:801-571-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT92078202402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty