Healthcare Provider Details

I. General information

NPI: 1477691160
Provider Name (Legal Business Name): KELLY M WIIG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 5TH ST
STORM LAKE IA
50588-1743
US

IV. Provider business mailing address

4385 HIGHWAY 20
CORRECTIONVILLE IA
51016-8028
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-7725
  • Fax: 712-732-5153
Mailing address:
  • Phone: 712-732-7725
  • Fax: 712-732-5153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number997
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: