Healthcare Provider Details

I. General information

NPI: 1023667953
Provider Name (Legal Business Name): EMILY JANE MANS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S PIONEER RD
FOND DU LAC WI
54935-3800
US

IV. Provider business mailing address

103 S PIONEER RD STE 100
FOND DU LAC WI
54935-3800
US

V. Phone/Fax

Practice location:
  • Phone: 920-922-7776
  • Fax:
Mailing address:
  • Phone: 920-922-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2965-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: