Provider Demographics
NPI:1912231234
Name:WINQUIST, TALITHA SHAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:TALITHA
Middle Name:SHAN
Last Name:WINQUIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4661
Mailing Address - Country:US
Mailing Address - Phone:270-842-4038
Mailing Address - Fax:
Practice Address - Street 1:818 LOIS LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4661
Practice Address - Country:US
Practice Address - Phone:270-842-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-001794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist