Healthcare Provider Details

I. General information

NPI: 1902112949
Provider Name (Legal Business Name): ANNA RAE PELNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA RAE KOENIG PTA

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 MAIN AVE
CRIVITZ WI
54114-1619
US

IV. Provider business mailing address

W6423 LITTLE RIVER RD
PESHTIGO WI
54157-9402
US

V. Phone/Fax

Practice location:
  • Phone: 715-854-2717
  • Fax:
Mailing address:
  • Phone: 920-606-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1638-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: