Provider Demographics
NPI:1003535071
Name:GRENAWALT, MAGNOLIA MAE (PTA)
Entity Type:Individual
Prefix:
First Name:MAGNOLIA
Middle Name:MAE
Last Name:GRENAWALT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-9776
Mailing Address - Country:US
Mailing Address - Phone:608-527-4390
Mailing Address - Fax:
Practice Address - Street 1:600 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574-9776
Practice Address - Country:US
Practice Address - Phone:608-527-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4002-19208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation