Provider Demographics
NPI:1447852348
Name:TEFFERA, WINTANA
Entity type:Individual
Prefix:
First Name:WINTANA
Middle Name:
Last Name:TEFFERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 BLUE MARLIN WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-8017
Mailing Address - Country:US
Mailing Address - Phone:585-752-9919
Mailing Address - Fax:
Practice Address - Street 1:75 S MILFORD DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9337
Practice Address - Country:US
Practice Address - Phone:317-736-4665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007248A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist