Provider Demographics
NPI:1346672490
Name:AMBORN, DANIELLE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:AMBORN
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 1:5335 SUNNYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3622
Mailing Address - Country:US
Mailing Address - Phone:218-729-6619
Mailing Address - Fax:
Practice Address - Street 1:8274 E SAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH RANGE
Practice Address - State:WI
Practice Address - Zip Code:54874-8621
Practice Address - Country:US
Practice Address - Phone:715-398-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1625-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant