Provider Demographics
NPI:1508560756
Name:FENNER, HEATHER (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FENNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:DICKEYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53808-0342
Mailing Address - Country:US
Mailing Address - Phone:608-723-9772
Mailing Address - Fax:
Practice Address - Street 1:159 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKEYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53808-6836
Practice Address - Country:US
Practice Address - Phone:608-723-9772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2474225200000X
IA083753225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant