Provider Demographics
NPI:1144430240
Name:FRAGALE, RENA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:LYNN
Last Name:FRAGALE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:RENA
Other - Middle Name:LYNN
Other - Last Name:SMYSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5050 S LAKE SHORE DR
Mailing Address - Street 2:APT 915
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3282
Mailing Address - Country:US
Mailing Address - Phone:281-838-2139
Mailing Address - Fax:
Practice Address - Street 1:5050 S LAKE SHORE DR
Practice Address - Street 2:APT 915
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-3282
Practice Address - Country:US
Practice Address - Phone:281-838-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2060433225200000X
IL160004844225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant