Provider Demographics
NPI:1740492404
Name:FETTERER, SAMANTHA LYN (PTA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LYN
Last Name:FETTERER
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 1:2120 BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-803-8316
Mailing Address - Fax:
Practice Address - Street 1:2629 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4932
Practice Address - Country:US
Practice Address - Phone:920-451-5550
Practice Address - Fax:920-451-5664
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40469600Medicaid