Provider Demographics
NPI:1639331515
Name:PURACKAL, REGINA ANN PUTHEN (PT)
Entity Type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:ANN PUTHEN
Last Name:PURACKAL
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 1:601 FELLOWSHIP WAY
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2425
Mailing Address - Country:US
Mailing Address - Phone:443-472-5630
Mailing Address - Fax:
Practice Address - Street 1:613 HAMMONDS LN
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MD
Practice Address - Zip Code:21225-3351
Practice Address - Country:US
Practice Address - Phone:410-350-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist