Provider Demographics
NPI:1396436507
Name:ALFONSO, MARY ELIZABETH (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:FARDINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3405 JUNO ST NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4503
Mailing Address - Country:US
Mailing Address - Phone:928-920-1511
Mailing Address - Fax:
Practice Address - Street 1:1301 N HIGHLANDS PKWY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2116
Practice Address - Country:US
Practice Address - Phone:253-752-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2171743225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant