Provider Demographics
NPI:1982211959
Name:WEITERMAN, DONNETTE (LMT)
Entity Type:Individual
Prefix:
First Name:DONNETTE
Middle Name:
Last Name:WEITERMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1328
Mailing Address - Country:US
Mailing Address - Phone:920-296-6650
Mailing Address - Fax:
Practice Address - Street 1:603 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2848
Practice Address - Country:US
Practice Address - Phone:920-296-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13930-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist