Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 32002303A | IN |
NPI | 1023352655 |
---|---|
Provider Name | Angie Timmons |
First Address | Fort Wayne, IN 46825-1668 |
Second Address | Fort Wayne, IN 46825-1668 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2012 |
Last Update Date | 20/11/2012 |