Healthcare Provider Details

I. General information

NPI: 1528302973
Provider Name (Legal Business Name): SHANTRICE LAFAVE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2012
Last Update Date: 11/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8274 E SAN RD
SOUTH RANGE WI
54874-8621
US

IV. Provider business mailing address

8274 E SAN RD
SOUTH RANGE WI
54874-8621
US

V. Phone/Fax

Practice location:
  • Phone: 715-398-3523
  • Fax:
Mailing address:
  • Phone: 715-398-3523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1444
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1841-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: