Provider Demographics
NPI:1669968012
Name:AXALAN, ANNGIE MAY (PT)
Entity type:Individual
Prefix:
First Name:ANNGIE MAY
Middle Name:
Last Name:AXALAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANNGIE MAY
Other - Middle Name:LAGARE
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7060 N DURANGO DR STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4605
Practice Address - Country:US
Practice Address - Phone:702-826-5749
Practice Address - Fax:702-273-3015
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013950225100000X
NV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist