Provider Demographics
NPI:1952452112
Name:BURTNESS, TAYNA M (PTA)
Entity Type:Individual
Prefix:
First Name:TAYNA
Middle Name:M
Last Name:BURTNESS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TAYNA
Other - Middle Name:M
Other - Last Name:NYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:557 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2907
Mailing Address - Country:US
Mailing Address - Phone:608-754-6000
Mailing Address - Fax:
Practice Address - Street 1:557 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2907
Practice Address - Country:US
Practice Address - Phone:608-754-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1017-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952452112Medicaid
WI40175300Medicaid