Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 05012263A | IN |
NPI | 1013464122 |
---|---|
Provider Name | Elaine Coleman Prouty |
First Address | Fort Wayne, IN 46818-8680 |
Second Address | Fort Wayne, IN 46818-8680 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2016 |
Last Update Date | 07/09/2016 |