Healthcare Provider Details

I. General information

NPI: 1760634901
Provider Name (Legal Business Name): DEANNA C WILKEN P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 YMCA DR SUITE 1200
FESTUS MO
63028-2661
US

IV. Provider business mailing address

1330 YMCA DR SUITE 1200
FESTUS MO
63028-2661
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-7600
  • Fax: 636-931-8808
Mailing address:
  • Phone: 636-931-7600
  • Fax: 636-931-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number116407
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: