Healthcare Provider Details

I. General information

NPI: 1124264478
Provider Name (Legal Business Name): THERESA ANN KNOLL MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA ANN YANIK MPT

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 S ALPINE RD PHYSICIANS IMMEDIATE CARE
ROCKFORD IL
61109-2604
US

IV. Provider business mailing address

210 SE PIONEER WAY STE 2
OAK HARBOR WA
98277-5705
US

V. Phone/Fax

Practice location:
  • Phone: 815-874-8000
  • Fax: 815-874-7525
Mailing address:
  • Phone: 360-679-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8149
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017118
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60736405
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: