Provider Demographics
NPI:1053468397
Name:WENNINGER, TAREY ANN (PT,)
Entity Type:Individual
Prefix:MRS
First Name:TAREY
Middle Name:ANN
Last Name:WENNINGER
Suffix:
Gender:F
Credentials:PT,
Other - Prefix:MISS
Other - First Name:TAREY
Other - Middle Name:ANN
Other - Last Name:FRANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT,
Mailing Address - Street 1:6123 GREEN BAY RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-653-9208
Mailing Address - Fax:262-653-9264
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-653-9208
Practice Address - Fax:262-653-9264
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6483-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801882451OtherNPI-INDVL