Provider Demographics
NPI:1376026062
Name:KANACK, AMANDA (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KANACK
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:PO BOX 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:262-408-5094
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376026062Medicaid