Provider Demographics
NPI:1679553416
Name:BRASE, ANN MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MICHELLE
Last Name:BRASE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 PALISADES RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-9576
Mailing Address - Country:US
Mailing Address - Phone:319-895-0718
Mailing Address - Fax:
Practice Address - Street 1:108 1ST ST E
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1421
Practice Address - Country:US
Practice Address - Phone:319-895-4085
Practice Address - Fax:319-895-8013
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA39797OtherBLUE CROSS BLUE SHEILD
IAI16437Medicare ID - Type Unspecified