Provider Demographics
NPI:1265090054
Name:FIAONI, GRACIE E (PTA)
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:E
Last Name:FIAONI
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 1:432 SOUTHAMPTON DR APT 2
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3061
Mailing Address - Country:US
Mailing Address - Phone:573-453-4155
Mailing Address - Fax:
Practice Address - Street 1:109 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6725
Practice Address - Country:US
Practice Address - Phone:573-443-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017036518225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant