Healthcare Provider Details

I. General information

NPI: 1295948362
Provider Name (Legal Business Name): CHALISA LOUISE FONZA M.A., ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2833 MARBLEWOOD DR
COLUMBUS OH
43219-5038
US

IV. Provider business mailing address

2833 MARBLEWOOD DR
COLUMBUS OH
43219-5038
US

V. Phone/Fax

Practice location:
  • Phone: 614-688-5890
  • Fax: 614-292-3258
Mailing address:
  • Phone: 614-688-5890
  • Fax: 614-292-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-000718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: