Provider Demographics
NPI:1063511061
Name:SWANKE, TINA LORENE (OTR)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LORENE
Last Name:SWANKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6681 COUNTY RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WI
Mailing Address - Zip Code:54968-9323
Mailing Address - Country:US
Mailing Address - Phone:920-229-0955
Mailing Address - Fax:
Practice Address - Street 1:147 N STATE ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1621
Practice Address - Country:US
Practice Address - Phone:920-361-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI729-026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40729700Medicaid