Provider Demographics
NPI:1720497100
Name:LANCE, RACHAEL
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:LANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S MURPHY AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-8316
Mailing Address - Country:US
Mailing Address - Phone:812-442-0403
Mailing Address - Fax:
Practice Address - Street 1:501 S MURPHY AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-8316
Practice Address - Country:US
Practice Address - Phone:812-442-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004449A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant