Provider Demographics
NPI:1750746483
Name:IANDIATAIYERO, KHEPERA (PT)
Entity type:Individual
Prefix:
First Name:KHEPERA
Middle Name:
Last Name:IANDIATAIYERO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 MARJEFF PL
Mailing Address - Street 2:APT C
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4514
Mailing Address - Country:US
Mailing Address - Phone:410-917-0524
Mailing Address - Fax:
Practice Address - Street 1:4011 MARJEFF PL
Practice Address - Street 2:APT C
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4514
Practice Address - Country:US
Practice Address - Phone:410-917-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist