Provider Demographics
NPI:1336840347
Name:FONZO, SANDRA DIANE (PTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DIANE
Last Name:FONZO
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 1:28 RHODES TER
Mailing Address - Street 2:
Mailing Address - City:HARVEYS LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18618-9777
Mailing Address - Country:US
Mailing Address - Phone:570-200-5866
Mailing Address - Fax:
Practice Address - Street 1:395 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-3806
Practice Address - Country:US
Practice Address - Phone:570-735-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008826225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty