Healthcare Provider Details

I. General information

NPI: 1750149878
Provider Name (Legal Business Name): CLAIRE STANNERS MAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 ALFORD PARK DR
KENOSHA WI
53140-1927
US

IV. Provider business mailing address

999 WOOD RD APT 203
KENOSHA WI
53144-1154
US

V. Phone/Fax

Practice location:
  • Phone: 173-478-7252
  • Fax:
Mailing address:
  • Phone: 734-787-2523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3145-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: