Provider Demographics
NPI:1245873637
Name:STURDEVANT, RACHEL ANNE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:STURDEVANT
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 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:13180 MARKET SQUARE DR STE 100
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-8390
Practice Address - Country:US
Practice Address - Phone:317-813-9322
Practice Address - Fax:317-813-9337
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010837A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05010837AOtherLICENSE