Provider Demographics
NPI:1154195220
Name:VETTER, MONTANNAH
Entity type:Individual
Prefix:
First Name:MONTANNAH
Middle Name:
Last Name:VETTER
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 1:15225 W TODD SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GLASFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61533-9720
Mailing Address - Country:US
Mailing Address - Phone:309-201-0603
Mailing Address - Fax:
Practice Address - Street 1:500 W ROMEO B GARRETT AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2301
Practice Address - Country:US
Practice Address - Phone:309-680-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009892225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant