Healthcare Provider Details

I. General information

NPI: 1558568972
Provider Name (Legal Business Name): ANGELA BLAIR WULKOPF PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ANSON ST
SALEM IN
47167-1982
US

IV. Provider business mailing address

6740 BROOKSIDE DR NE
LANESVILLE IN
47136-8902
US

V. Phone/Fax

Practice location:
  • Phone: 812-883-4681
  • Fax: 812-883-8113
Mailing address:
  • Phone: 812-952-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001953A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: