Provider Demographics
NPI:1386115160
Name:FAYARD, MALINDA C (PT)
Entity type:Individual
Prefix:MRS
First Name:MALINDA
Middle Name:C
Last Name:FAYARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10327 SHADY PINE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39565-9325
Mailing Address - Country:US
Mailing Address - Phone:228-547-6614
Mailing Address - Fax:
Practice Address - Street 1:6017 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-2648
Practice Address - Country:US
Practice Address - Phone:228-547-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT31732251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty