Provider Demographics
NPI:1306611140
Name:FERMANICH, MOLLY JEAN (PTA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JEAN
Last Name:FERMANICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9209 COUNTY ROAD F
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-9116
Mailing Address - Country:US
Mailing Address - Phone:715-219-3837
Mailing Address - Fax:
Practice Address - Street 1:4810 BARBICAN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-4186
Practice Address - Country:US
Practice Address - Phone:715-393-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4098-19208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation