Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 12226 | WI |
NPI | 1003254855 |
---|---|
Provider Name | Mckenzie Fauth |
First Address | Hartland, WI 53029-1651 |
Second Address | Greenfield, WI 53220-4016 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2013 |
Last Update Date | 13/06/2013 |