Provider Demographics
NPI:1659380707
Name:WALKOWIAK, WANDA LEA (RPT)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:LEA
Last Name:WALKOWIAK
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:LEA
Other - Last Name:FRASER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05363-0716
Mailing Address - Country:US
Mailing Address - Phone:802-464-3151
Mailing Address - Fax:802-464-3116
Practice Address - Street 1:30 VT ROUTE 100 S
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:VT
Practice Address - Zip Code:05363-7944
Practice Address - Country:US
Practice Address - Phone:802-464-3151
Practice Address - Fax:802-464-3116
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
382118OtherMVP
VT00068343OtherBCBS
382118OtherMVP