Provider Demographics
NPI:1891097044
Name:INDLAMURI, RENUKA
Entity type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:INDLAMURI
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 1:10120 JEFFERSON WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2178
Mailing Address - Country:US
Mailing Address - Phone:571-420-2030
Mailing Address - Fax:
Practice Address - Street 1:2940 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1910
Practice Address - Country:US
Practice Address - Phone:260-484-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-21
Last Update Date:2010-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010214A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist