Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 070020357 | IL |
NPI | 1063814309 |
---|---|
Provider Name | Lakshmi Kalyani Gudavalli |
First Address | Bettendorf, IA 52722-7554 |
Second Address | Galesburg, IL 61401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2014 |
Last Update Date | 18/09/2014 |