=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396287611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLYNN RUSCH DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2016
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N7135 ROCKY KNOLL PKWY
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53073-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-449-1254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W6186 CTY RD
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53073-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 13198-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------