Provider Demographics
NPI:1699020990
Name:ABLOG, MARIE ANTONETTE FERNANDEZ (PT)
Entity Type:Individual
Prefix:
First Name:MARIE ANTONETTE
Middle Name:FERNANDEZ
Last Name:ABLOG
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 1:16089 POPPYSEED CIR
Mailing Address - Street 2:UNIT 2008
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6314
Mailing Address - Country:US
Mailing Address - Phone:561-496-7993
Mailing Address - Fax:561-496-0589
Practice Address - Street 1:4111 WESTCITY CT
Practice Address - Street 2:APT. 79
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1647
Practice Address - Country:US
Practice Address - Phone:682-203-1702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1215548225100000X
IL070.018423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist