Provider Demographics
NPI:1629471248
Name:BEDWELL, TONDALAYA
Entity Type:Individual
Prefix:MRS
First Name:TONDALAYA
Middle Name:
Last Name:BEDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TONDALAYA
Other - Middle Name:RENE
Other - Last Name:BEDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:4201 SENICA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9372
Mailing Address - Country:US
Mailing Address - Phone:260-704-1435
Mailing Address - Fax:
Practice Address - Street 1:10445 DUPONT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8792
Practice Address - Country:US
Practice Address - Phone:260-471-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-28
Last Update Date:2014-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002104A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist