Provider Demographics
NPI:1942452891
Name:KRIESE, ANDREA KATHLEEN
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:KATHLEEN
Last Name:KRIESE
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 1:1570 MIDWAY PL
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1165
Mailing Address - Country:US
Mailing Address - Phone:920-720-1464
Mailing Address - Fax:
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:PHYSICAL THERAPY DEPT
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-738-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11072-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist