Healthcare Provider Details

I. General information

NPI: 1891064556
Provider Name (Legal Business Name): NICOLE ALLENDORF PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 26TH AVE
MONROE WI
53566-1531
US

IV. Provider business mailing address

5104 E STAGECOACH TRL
APPLE RIVER IL
61001-9405
US

V. Phone/Fax

Practice location:
  • Phone: 608-329-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: