Provider Demographics
NPI:1578042297
Name:BANNISTER, HEATHER LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:BANNISTER
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-0247
Mailing Address - Country:US
Mailing Address - Phone:715-304-8470
Mailing Address - Fax:
Practice Address - Street 1:1436 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3427
Practice Address - Country:US
Practice Address - Phone:715-526-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2836-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant