Provider Demographics
NPI:1114251584
Name:HOLMES, PENNY M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:M
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2903
Mailing Address - Country:US
Mailing Address - Phone:608-329-6601
Mailing Address - Fax:608-329-6604
Practice Address - Street 1:1905 5TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53203-2903
Practice Address - Country:US
Practice Address - Phone:608-329-6601
Practice Address - Fax:608-329-6604
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1614-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526562Medicare PIN