Provider Demographics
NPI:1316604796
Name:YENNU, ARCHANA (PT, DPT)
Entity type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:YENNU
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11909 FIREKAT CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2164
Mailing Address - Country:US
Mailing Address - Phone:269-532-6096
Mailing Address - Fax:
Practice Address - Street 1:12523 AUBURN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-0201
Practice Address - Country:US
Practice Address - Phone:260-637-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011901A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist