Provider Demographics
NPI:1508265091
Name:REZANSOFF, ABBY RAE
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:RAE
Last Name:REZANSOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:RAE
Other - Last Name:BANDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:SOUTH 2 ROOM 236
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-6228
Mailing Address - Fax:515-241-8685
Practice Address - Street 1:2006 S ANKENY BLVD
Practice Address - Street 2:BUILDING 6
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-8995
Practice Address - Country:US
Practice Address - Phone:515-289-9541
Practice Address - Fax:515-446-3642
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4260225100000X
IA082377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508265091Medicaid