Healthcare Provider Details

I. General information

NPI: 1396834172
Provider Name (Legal Business Name): MARY KAY SOLON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 E DUPONT RD STE 7
FORT WAYNE IN
46825-1545
US

IV. Provider business mailing address

714 STRATTON RD
FORT WAYNE IN
46825-5441
US

V. Phone/Fax

Practice location:
  • Phone: 260-490-0940
  • Fax: 260-490-5063
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number05000775A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: