Healthcare Provider Details

I. General information

NPI: 1629327200
Provider Name (Legal Business Name): ANNA WISSINK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S. NINTH ST. RENNES HEALTH AND REHAB CENTER,
DE PERE WI
54115
US

IV. Provider business mailing address

411 ST. MARY'S BLVD
GREEN BAY WI
54301
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-4145
  • Fax: 920-338-9121
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1930-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: