Provider Demographics
NPI:1124507298
Name:WALTENBERRY, KATHERINE KRISTINE
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:KRISTINE
Last Name:WALTENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:KRISTINE
Other - Last Name:RAE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 SOUTHERN EDGE DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6040
Mailing Address - Country:US
Mailing Address - Phone:920-238-0598
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4597
Practice Address - Country:US
Practice Address - Phone:920-929-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3611225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist