Healthcare Provider Details

I. General information

NPI: 1922380260
Provider Name (Legal Business Name): JOANNA FAUGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CARROLLTON EST
MATTOON IL
61938-9598
US

IV. Provider business mailing address

11315 CORPORATE BLVD SUITE 100
ORLANDO FL
32817-8344
US

V. Phone/Fax

Practice location:
  • Phone: 217-259-7353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160005726
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: