Provider Demographics
NPI:1336787241
Name:FOSTER, NANCY ANNE (PTA)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ANNE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:ANNE
Other - Last Name:BLACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:4300 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2918
Mailing Address - Country:US
Mailing Address - Phone:951-222-2206
Mailing Address - Fax:
Practice Address - Street 1:13800 HEACOCK ST STE C136
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3363
Practice Address - Country:US
Practice Address - Phone:951-656-6009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA6679225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTA6679OtherLICENSE NUMBER