Provider Demographics
NPI:1649839416
Name:PRALLE, TABITHA LYNN
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:PRALLE
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:E8521 COUNTY HIGHWAY M
Mailing Address - Street 2:
Mailing Address - City:READSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54652-8025
Mailing Address - Country:US
Mailing Address - Phone:608-632-4479
Mailing Address - Fax:
Practice Address - Street 1:E8521 COUNTY HIGHWAY M
Practice Address - Street 2:
Practice Address - City:READSTOWN
Practice Address - State:WI
Practice Address - Zip Code:54652-8025
Practice Address - Country:US
Practice Address - Phone:608-632-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2942-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant