Provider Demographics
NPI:1700369386
Name:RENDON ZAVALA, MIRIAM BERENICE (PTA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:BERENICE
Last Name:RENDON ZAVALA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 W EDGEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85035-2212
Mailing Address - Country:US
Mailing Address - Phone:480-386-2166
Mailing Address - Fax:
Practice Address - Street 1:6550 E 2ND ST STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-3523
Practice Address - Country:US
Practice Address - Phone:928-777-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ013789225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant