Provider Demographics
NPI:1609030493
Name:ELVINIA, MARIA ROSE LALYN TAN
Entity Type:Individual
Prefix:
First Name:MARIA ROSE LALYN
Middle Name:TAN
Last Name:ELVINIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 WIND DRIFT DR E
Mailing Address - Street 2:APT 1D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7301 E 16TH STREET
Practice Address - Street 2:WILDWOOD HEALTH CARE CENTER
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219
Practice Address - Country:US
Practice Address - Phone:317-353-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008445A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist