Provider Demographics
NPI:1154721256
Name:EVERMON, NATALIE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:LYNN
Last Name:EVERMON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:LYNN
Other - Last Name:KRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8535 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6412
Mailing Address - Country:US
Mailing Address - Phone:262-455-5382
Mailing Address - Fax:
Practice Address - Street 1:8535 19TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6412
Practice Address - Country:US
Practice Address - Phone:262-455-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant