Healthcare Provider Details

I. General information

NPI: 1265206395
Provider Name (Legal Business Name): MIKAYLA ROSE SURPRENANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 WASHINGTON RD STE A
KENOSHA WI
53144-1640
US

IV. Provider business mailing address

3615 WASHINGTON RD STE A
KENOSHA WI
53144-1640
US

V. Phone/Fax

Practice location:
  • Phone: 262-287-0090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7107-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: