Provider Demographics
NPI:1093029092
Name:NOLDEN, LISA M (PTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:NOLDEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2176
Mailing Address - Street 2:DEPT 5389
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2176
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:1663 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-9306
Practice Address - Country:US
Practice Address - Phone:815-544-0040
Practice Address - Fax:815-544-0048
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769380OtherMEDICARE GROUP PTAN
IL160004668OtherIL LICENSE