Provider Demographics
NPI:1679708580
Name:MARCOUILLER, KATIE ANNE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:MARCOUILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4713
Mailing Address - Country:US
Mailing Address - Phone:920-456-7103
Mailing Address - Fax:920-303-8131
Practice Address - Street 1:135 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4713
Practice Address - Country:US
Practice Address - Phone:920-456-7103
Practice Address - Fax:920-303-8131
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10467-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist