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General NPI Number Information
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NPI Number | 1013519479
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Entity Type | Individual
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Provider Name | BRIANA LYNN TECKENBURG PTA
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Gender | Female
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Dates
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Enumeration Date | 11/11/2020
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Last Update Date | 04/28/2022
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Provider Practice Location Address
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Address Line | 459 E 1ST ST
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City | FOND DU LAC
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State | WI
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Zip | 54935-4505
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Country | US
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Telephone | 920-929-3500
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Fax |
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Provider Business Mailing Address
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Address Line | 1336 STONE RIDGE RD APT 58
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City | WAUPACA
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State | WI
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Zip | 54981-8639
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Country | US
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Telephone | 641-849-0516
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 3107-19
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License Number State | WI
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