Basic Information
Provider Information | |||||||||
NPI: | 1982846044 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTA CLARA | ||||||||
FirstName: | ANNA KHRUZETTE | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ARANGUREN | ||||||||
OtherFirstName: | KHRUZETTE | ||||||||
OtherMiddleName: | CABANCE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.T. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2700 QUARRY LAKE DR | ||||||||
Address2: | BALTIMORE | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212093742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103778900 | ||||||||
FaxNumber: | 4103773156 | ||||||||
Practice Location | |||||||||
Address1: | 2700 QUARRY LAKE DR | ||||||||
Address2: | BALTIMORE | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212093742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103778900 | ||||||||
FaxNumber: | 4103773156 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2009 | ||||||||
LastUpdateDate: | 10/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 21935 | 01 | MD | LICENSE NUMBER | OTHER |