Healthcare Provider Details

I. General information

NPI: 1316608425
Provider Name (Legal Business Name): CAITLIN KEHOE NIMM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2022
Last Update Date: 01/02/2022
Certification Date: 01/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

328 1/2 NOBLE AVE APT SUITE
RICE LAKE WI
54868-2048
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4297
  • Fax:
Mailing address:
  • Phone: 715-864-0447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3219-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: