Provider Demographics
NPI:1831865302
Name:FENNIG, RANDI ROSE
Entity type:Individual
Prefix:MISS
First Name:RANDI
Middle Name:ROSE
Last Name:FENNIG
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 1:10355 W PLUM TREE CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2634
Mailing Address - Country:US
Mailing Address - Phone:414-614-1244
Mailing Address - Fax:
Practice Address - Street 1:6263 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3823
Practice Address - Country:US
Practice Address - Phone:414-351-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314319225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI314319OtherPHYSICAL THERAPIST ASSISTANT