Healthcare Provider Details

I. General information

NPI: 1265757751
Provider Name (Legal Business Name): LAURIE ANNE REPOLL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 HOSPITAL DR
FAIRHOPE AL
36532-2058
US

IV. Provider business mailing address

557 JAN DR
FAIRHOPE AL
36532-2713
US

V. Phone/Fax

Practice location:
  • Phone: 251-279-1640
  • Fax: 251-279-1494
Mailing address:
  • Phone: 251-279-1640
  • Fax: 251-279-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH 2254
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: