Provider Demographics
NPI:1629580402
Name:MOMBER, REANNA JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:REANNA
Middle Name:JEAN
Last Name:MOMBER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:REANNA
Other - Middle Name:JEAN
Other - Last Name:PADDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:2307 HILLSHIRE DR APT 3C
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-5475
Mailing Address - Country:US
Mailing Address - Phone:262-707-2969
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5396-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant