Provider Demographics
NPI:1316440738
Name:FOX, ALAITIA RAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ALAITIA
Middle Name:RAE
Last Name:FOX
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ALAITIA
Other - Middle Name:
Other - Last Name:ENJADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:2915 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ375127Medicaid