Provider Demographics
NPI:1497209001
Name:KOLLER, AUDREY (PTA)
Entity Type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:
Last Name:KOLLER
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 1:123 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3069
Mailing Address - Country:US
Mailing Address - Phone:608-764-0009
Mailing Address - Fax:
Practice Address - Street 1:106 S HOLMEN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9467
Practice Address - Country:US
Practice Address - Phone:608-526-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2206225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant