Healthcare Provider Details

I. General information

NPI: 1376760264
Provider Name (Legal Business Name): AGNES LUCAS VIGILIA-MARAYA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 NORTHBURY DR
FORT WAYNE IN
46818-1843
US

IV. Provider business mailing address

8110 NORTHBURY DR
FORT WAYNE IN
46818-1843
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-3704
  • Fax: 260-489-3704
Mailing address:
  • Phone: 260-489-3704
  • Fax: 260-489-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT05002613A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: