Healthcare Provider Details

I. General information

NPI: 1174454078
Provider Name (Legal Business Name): CHARLIE RAVANELLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S. ONEIDA STREET
APPLETON WI
54915
US

IV. Provider business mailing address

12211 N WILLOW GLENN CT
MEQUON WI
53092-3331
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax:
Mailing address:
  • Phone: 262-395-0085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17759-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: