Healthcare Provider Details

I. General information

NPI: 1366401150
Provider Name (Legal Business Name): ANN MARIE PONDROM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 OLD ROUTE 66
ST ROBERT MO
65584-3730
US

IV. Provider business mailing address

14310 HOWARD LN
DIXON MO
65459-7329
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-8991
  • Fax: 573-336-8993
Mailing address:
  • Phone: 573-336-3490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number110413
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: