Provider Demographics
NPI:1629734561
Name:AVELLANEDA, JENNY PAOLA
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:PAOLA
Last Name:AVELLANEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:PAOLA
Other - Last Name:AVELLANEDA MENDOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:704-323-3611
Mailing Address - Fax:
Practice Address - Street 1:601 SUTTON RD S
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8439
Practice Address - Country:US
Practice Address - Phone:803-909-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist