Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10030-024 | WI |
NPI | 1003094558 |
---|---|
Provider Name | Mrs. Elizabeth Mary Roe |
First Address | Sun Prairie, WI 53590-1239 |
Second Address | Sun Prairie, WI 53590-1239 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2008 |
Last Update Date | 23/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1578570974 | (05) | WI |