Provider Demographics
NPI:1477102101
Name:FAIOLA, ANNA ALEXANDER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:ALEXANDER
Last Name:FAIOLA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N CHAUNCEY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2701
Mailing Address - Country:US
Mailing Address - Phone:765-414-8233
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-4150
Practice Address - Fax:773-521-5092
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist