Provider Demographics
NPI:1649625310
Name:BAGNALL, ANDREA RENEE (ATC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:RENEE
Last Name:BAGNALL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 W PALO VERDE ST
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-5336
Mailing Address - Country:US
Mailing Address - Phone:928-651-4245
Mailing Address - Fax:928-428-2378
Practice Address - Street 1:2934 W PALO VERDE ST
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:AZ
Practice Address - Zip Code:85552
Practice Address - Country:US
Practice Address - Phone:928-651-4245
Practice Address - Fax:928-428-2378
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ02482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer