Provider Demographics
NPI:1437439239
Name:BROQUET, MADONNA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:MARIE
Last Name:BROQUET
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 369
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-0369
Mailing Address - Country:US
Mailing Address - Phone:847-421-2148
Mailing Address - Fax:
Practice Address - Street 1:3516 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5732
Practice Address - Country:US
Practice Address - Phone:815-271-5249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001738225200000X
WI1441-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant