Provider Demographics
NPI:1063890903
Name:BENNETT, RAEANN JO (D-PT)
Entity type:Individual
Prefix:
First Name:RAEANN
Middle Name:JO
Last Name:BENNETT
Suffix:
Gender:F
Credentials:D-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:833 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-3092
Practice Address - Fax:920-846-8313
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK300225197Medicare Oscar/Certification
WIK400225165Medicare Oscar/Certification
WIK400225335Medicare Oscar/Certification
WIK400225333Medicare Oscar/Certification