Healthcare Provider Details

I. General information

NPI: 1265002620
Provider Name (Legal Business Name): HANNAH BROOKE ZAK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HANNAH BLYSTONE

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3946 ICE WAY
FORT WAYNE IN
46805-1018
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-7400
  • Fax: 260-266-4008
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number05014209A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05014209A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: