Healthcare Provider Details

I. General information

NPI: 1649836370
Provider Name (Legal Business Name): MISS BROOKE ANZALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 B BENDEL RD SUITE C
LAFAYETTE LA
70503
US

IV. Provider business mailing address

P.O. BOX 80480
LAFAYETTE LA
70596-0480
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-9940
  • Fax: 337-981-2531
Mailing address:
  • Phone: 337-981-9940
  • Fax: 337-981-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10037
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: