Provider Demographics
NPI:1962692137
Name:AFOLABI, ANDRENA K (PTA)
Entity type:Individual
Prefix:MISS
First Name:ANDRENA
Middle Name:K
Last Name:AFOLABI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7061 SAUVAGE LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-1682
Mailing Address - Country:US
Mailing Address - Phone:617-504-4071
Mailing Address - Fax:
Practice Address - Street 1:200 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1644
Practice Address - Country:US
Practice Address - Phone:781-391-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7884225200000X
MDA3952225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant