Provider Demographics
NPI:1013463512
Name:MENKE, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MENKE
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 1:741 N HALL ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-1448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 104TH
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8312
Practice Address - Country:US
Practice Address - Phone:419-604-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0162062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics