Provider Demographics
NPI:1205143096
Name:FERIDO, AVA NATHALIE V
Entity type:Individual
Prefix:
First Name:AVA NATHALIE
Middle Name:V
Last Name:FERIDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W FULLERTON PKWY
Mailing Address - Street 2:APT. 115
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2869
Mailing Address - Country:US
Mailing Address - Phone:312-480-0961
Mailing Address - Fax:
Practice Address - Street 1:420 W FULLERTON PKWY
Practice Address - Street 2:APT. 115
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2869
Practice Address - Country:US
Practice Address - Phone:312-480-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist