Healthcare Provider Details

I. General information

NPI: 1386818938
Provider Name (Legal Business Name): MYRTLE FAYE EATON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 N 68TH ST
MILWAUKEE WI
53216-1118
US

IV. Provider business mailing address

4355 N 68TH ST
MILWAUKEE WI
53216-1118
US

V. Phone/Fax

Practice location:
  • Phone: 414-536-6160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number665-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: