Provider Demographics
NPI:1235667353
Name:GANGESTAD, ERLENE ANN
Entity Type:Individual
Prefix:
First Name:ERLENE
Middle Name:ANN
Last Name:GANGESTAD
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 1:7111 189TH ST
Mailing Address - Street 2:
Mailing Address - City:ALBIA
Mailing Address - State:IA
Mailing Address - Zip Code:52531-8770
Mailing Address - Country:US
Mailing Address - Phone:641-226-1576
Mailing Address - Fax:
Practice Address - Street 1:3 PENNSYLVANIA PL
Practice Address - Street 2:VISTA WOODS
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-683-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00769225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant