Healthcare Provider Details

I. General information

NPI: 1588852099
Provider Name (Legal Business Name): NINA M. MINNEAR PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MILL ST THEDACARE MEDICAL CENTER NEW LONDON
NEW LONDON WI
54961-2155
US

IV. Provider business mailing address

1405 MILL ST THEDACARE MEDICAL CENTER NEW LONDON
NEW LONDON WI
54961-2155
US

V. Phone/Fax

Practice location:
  • Phone: 920-531-2031
  • Fax: 920-531-2056
Mailing address:
  • Phone: 920-531-2031
  • Fax: 920-531-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10457-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.014662
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9897
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: