Provider Demographics
NPI:1679934764
Name:FONDEKAR, TANYA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:FONDEKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N WABASH RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1300
Mailing Address - Country:US
Mailing Address - Phone:765-651-3229
Mailing Address - Fax:765-651-3227
Practice Address - Street 1:275 W 12TH ST
Practice Address - Street 2:4 WEST
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1638
Practice Address - Country:US
Practice Address - Phone:765-475-2160
Practice Address - Fax:765-475-2164
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011795A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist