Provider Demographics
NPI:1346240405
Name:PRUYNE, ANN LOUISE (OT)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:LOUISE
Last Name:PRUYNE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 E AZALEA TER
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1606
Mailing Address - Country:US
Mailing Address - Phone:608-290-4584
Mailing Address - Fax:608-362-6065
Practice Address - Street 1:828 E AZALEA TER
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1606
Practice Address - Country:US
Practice Address - Phone:608-290-4584
Practice Address - Fax:608-362-6065
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-000372208100000X
WI2095-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40904200Medicaid
WIP01085357OtherRR MEDICARE
IL209117K15602Medicare UPIN
WI000800008Medicare PIN