Provider Demographics
NPI:1437326311
Name:ERNST, VICKIE L (PTA)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:L
Last Name:ERNST
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:N87W17309 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2760
Mailing Address - Country:US
Mailing Address - Phone:262-257-4740
Mailing Address - Fax:
Practice Address - Street 1:N87W17309 MAIN ST
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2760
Practice Address - Country:US
Practice Address - Phone:262-257-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI117-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40356500Medicaid