Provider Demographics
NPI:1073740627
Name:FLANNERY, KATIE A (PT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:A
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:880 INDEPENDENCE LN
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583-1381
Mailing Address - Country:US
Mailing Address - Phone:608-643-2343
Mailing Address - Fax:
Practice Address - Street 1:880 INDEPENDENCE LN
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1381
Practice Address - Country:US
Practice Address - Phone:608-643-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073740627Medicaid