Healthcare Provider Details

I. General information

NPI: 1730445925
Provider Name (Legal Business Name): SHAWN LANNY ZIMMERLEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 E KING RD
TOMAHAWK WI
54487-1513
US

IV. Provider business mailing address

2311 FOREST DR
TOMAHAWK WI
54487-9356
US

V. Phone/Fax

Practice location:
  • Phone: 715-965-2622
  • Fax:
Mailing address:
  • Phone: 715-965-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1826-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: