Provider Demographics
NPI:1104038165
Name:DIXON, LANAN RAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LANAN
Middle Name:RAE
Last Name:DIXON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WASHINGTON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3043
Mailing Address - Country:US
Mailing Address - Phone:920-553-8993
Mailing Address - Fax:920-553-8990
Practice Address - Street 1:1400 WASHINGTON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3043
Practice Address - Country:US
Practice Address - Phone:920-553-8993
Practice Address - Fax:920-553-8990
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4947-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40295900Medicaid