Provider Demographics
NPI:1619676616
Name:DE LUNA PEREZ, ALONDRA
Entity Type:Individual
Prefix:
First Name:ALONDRA
Middle Name:
Last Name:DE LUNA PEREZ
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 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:800-341-1703
Mailing Address - Fax:877-719-4609
Practice Address - Street 1:157 RIVER RD
Practice Address - Street 2:
Practice Address - City:LIGONIER
Practice Address - State:IN
Practice Address - Zip Code:46767-9111
Practice Address - Country:US
Practice Address - Phone:260-894-9909
Practice Address - Fax:260-894-9913
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006338A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06006338AOtherPTA LICENSE