Provider Demographics
NPI:1841547700
Name:PRENGEL, EMILY KAY (PTA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:KAY
Last Name:PRENGEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:KAY
Other - Last Name:BONIFAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1277
Mailing Address - Country:US
Mailing Address - Phone:779-771-6867
Mailing Address - Fax:
Practice Address - Street 1:4401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1277
Practice Address - Country:US
Practice Address - Phone:779-771-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005881225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant