Provider Demographics
NPI:1710286117
Name:ANZALONE, SUSAN MARIE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:MARIE
Last Name:ANZALONE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 N CRESTHAVEN AVE
Mailing Address - Street 2:H206
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-7826
Mailing Address - Country:US
Mailing Address - Phone:314-494-1304
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:417-836-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110057582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer