Provider Demographics
NPI:1083092795
Name:MCGUIRE, ALENA ROSE
Entity Type:Individual
Prefix:
First Name:ALENA
Middle Name:ROSE
Last Name:MCGUIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 PRAIRIE GARDEN TRL
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-3958
Mailing Address - Country:US
Mailing Address - Phone:920-621-7520
Mailing Address - Fax:
Practice Address - Street 1:2717 PRAIRIE GARDEN TRL
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-3958
Practice Address - Country:US
Practice Address - Phone:920-621-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
WIM260-0169-4587-07390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer