Provider Demographics
NPI:1265449474
Name:KOONIN, ANGELA M (PT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:KOONIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:449 N WENDOVER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1064
Mailing Address - Country:US
Mailing Address - Phone:704-366-7723
Mailing Address - Fax:704-366-7724
Practice Address - Street 1:449 N WENDOVER RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-366-7723
Practice Address - Fax:704-366-7724
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC8265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212126Medicaid
NC078HKOtherBCBSNC
NCB2961OtherMEDCOST
NC7212126Medicaid