Healthcare Provider Details

I. General information

NPI: 1285796268
Provider Name (Legal Business Name): PENNY PETERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 N LEONARD ST
WEST SALEM WI
54669-1229
US

IV. Provider business mailing address

W7812 AMSTERDAM PRAIRIE RD
HOLMEN WI
54636-9394
US

V. Phone/Fax

Practice location:
  • Phone: 608-786-2274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number60-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: