Healthcare Provider Details

I. General information

NPI: 1427297688
Provider Name (Legal Business Name): LYNETTE VANAUSDALE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARKET PL SUITE 203
FAIRVIEW HEIGHTS IL
62208-2034
US

IV. Provider business mailing address

141 MARKET PL SUITE 203
FAIRVIEW HEIGHTS IL
62208-2034
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4118
  • Fax: 847-881-9640
Mailing address:
  • Phone: 618-398-4118
  • Fax: 847-881-9640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1400909
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: