Healthcare Provider Details

I. General information

NPI: 1841670015
Provider Name (Legal Business Name): JILL VANSTRYDONK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W MOHAWK DR MINISTRY HEAD 2 TOE THERAPY
TOMAHAWK WI
54487
US

IV. Provider business mailing address

2251 N SHORE DR STE 100
RHINELANDER WI
54501-6710
US

V. Phone/Fax

Practice location:
  • Phone: 715-453-6403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2021-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: