Provider Demographics
NPI:1669619151
Name:NENNEMAN, MICHELLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:NENNEMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525
Mailing Address - Country:US
Mailing Address - Phone:608-365-7500
Mailing Address - Fax:
Practice Address - Street 1:1905 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-365-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI861019225200000X
IL160002250225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant