Provider Demographics
NPI:1467438135
Name:PFANNERSTILL, TRACY (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:PFANNERSTILL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:EYNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:14625 W CAPITOL DRIVE
Mailing Address - Street 2:#200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2706
Mailing Address - Country:US
Mailing Address - Phone:262-790-9800
Mailing Address - Fax:262-790-9893
Practice Address - Street 1:14625 W CAPITOL DRIVE
Practice Address - Street 2:STE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2706
Practice Address - Country:US
Practice Address - Phone:262-790-9800
Practice Address - Fax:262-790-9893
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4379-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP55512Medicare UPIN
WI000281085Medicare ID - Type Unspecified