Provider Demographics
NPI:1568008944
Name:DE FIESTA, EVA (PT)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:DE FIESTA
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 1:105 ORCHARD HILLS DR APT 92
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8281
Mailing Address - Country:US
Mailing Address - Phone:502-819-3765
Mailing Address - Fax:
Practice Address - Street 1:CAREFIRST REHAB
Practice Address - Street 2:7225NOVA'S LANDING
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172
Practice Address - Country:US
Practice Address - Phone:812-748-7433
Practice Address - Fax:812-748-7442
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013477A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist