Provider Demographics
NPI:1902297906
Name:FERNANDEZ, MARY ANN DREZA ALINO (PT, COMT)
Entity Type:Individual
Prefix:
First Name:MARY ANN DREZA
Middle Name:ALINO
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PT, COMT
Other - Prefix:
Other - First Name:MARY ANN DREZA
Other - Middle Name:ALINO
Other - Last Name:BUENAVENTURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, COMT
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:63 HOSPITALITY LN STE 3
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:WV
Practice Address - Zip Code:26150-6705
Practice Address - Country:US
Practice Address - Phone:304-489-8100
Practice Address - Fax:304-489-8191
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000839225100000X
VA0105003469225100000X
WI13262-24225100000X
GAPT003437225100000X
WVPT000839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist