Provider Demographics
NPI:1639669500
Name:REYES, AUDREY ROSE PAGTALUNAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY ROSE
Middle Name:PAGTALUNAN
Last Name:REYES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AUDREY ROSE
Other - Middle Name:REYES
Other - Last Name:LEGASTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:728 ALEXANDRA PARK DR APT 102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 TREETOP DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-0606
Practice Address - Country:US
Practice Address - Phone:910-488-9008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist