Basic Information
| Provider Information | |||||||||
| NPI: | 1508265091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REZANSOFF | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | RAE | ||||||||
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| OtherLastName: | BANDY | ||||||||
| OtherFirstName: | ABBY | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT ST | ||||||||
| Address2: | SOUTH 2 ROOM 236 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152416228 | ||||||||
| FaxNumber: | 5152418685 | ||||||||
| Practice Location | |||||||||
| Address1: | 2006 S ANKENY BLVD | ||||||||
| Address2: | BUILDING 6 | ||||||||
| City: | ANKENY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500238995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152899541 | ||||||||
| FaxNumber: | 5154463642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2014 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4260 | ME | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 082377 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1508265091 | 05 | IA | MEDICAID |