Provider Demographics
NPI:1487675500
Name:KLUG, NANCY DETTMANN (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:DETTMANN
Last Name:KLUG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 W GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2765
Mailing Address - Country:US
Mailing Address - Phone:262-238-1121
Mailing Address - Fax:
Practice Address - Street 1:2025 E NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2906
Practice Address - Country:US
Practice Address - Phone:414-961-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2189024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist