Provider Demographics
NPI:1659538429
Name:IBANEZ-WONG, AILEEN (MPT)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:
Last Name:IBANEZ-WONG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1422
Mailing Address - Country:US
Mailing Address - Phone:478-718-8547
Mailing Address - Fax:
Practice Address - Street 1:840 PINE ST STE 880
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7525
Practice Address - Country:US
Practice Address - Phone:478-743-7092
Practice Address - Fax:478-743-6293
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0076622251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics