=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861284481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANA WASIELEWSKI DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2025
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2223 LIME KILN RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-6234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-425-7140
-----------------------------------------------------
Fax | 920-425-7144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2105 E ENTERPRISE AVE STE 113
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54913-7862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-991-2561
-----------------------------------------------------
Fax | 920-991-2563
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 17185-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------