Provider Demographics
NPI:1417183120
Name:WAALKENS, LAURA JEAN (LAT, PTA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:WAALKENS
Suffix:
Gender:F
Credentials:LAT, PTA
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:BOOKWALTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:1215 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5223
Mailing Address - Country:US
Mailing Address - Phone:920-645-3062
Mailing Address - Fax:
Practice Address - Street 1:5000 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-7316
Practice Address - Country:US
Practice Address - Phone:920-794-5381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2719-019225200000X
WI999-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer