Provider Demographics
NPI:1497025043
Name:VANEGEREN, STACY MARIE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:VANEGEREN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:TOONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2961 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5860
Mailing Address - Country:US
Mailing Address - Phone:920-468-0861
Mailing Address - Fax:920-468-5869
Practice Address - Street 1:2961 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5860
Practice Address - Country:US
Practice Address - Phone:920-468-0861
Practice Address - Fax:920-468-5869
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1471-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497025043Medicaid