Healthcare Provider Details

I. General information

NPI: 1407222540
Provider Name (Legal Business Name): MARA LYNN YATA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARA LYNN STOFFEL

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7878 N 76TH ST
MILWAUKEE WI
53223-3914
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-586-5760
  • Fax: 414-586-5740
Mailing address:
  • Phone: 414-586-5710
  • Fax: 414-586-5740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: