Provider Demographics
NPI:1285985903
Name:KLONDIKE, MARY ANGELIQUE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELIQUE
Last Name:KLONDIKE
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 1:8004 ASHDOWNE CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3594 SPRINGHURST BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-4141
Practice Address - Country:US
Practice Address - Phone:502-339-4700
Practice Address - Fax:502-339-7050
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00183225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant