Provider Demographics
NPI:1528109667
Name:TAMMINGA, JANNA SUE (PT)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:SUE
Last Name:TAMMINGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-4349
Mailing Address - Country:US
Mailing Address - Phone:608-289-9797
Mailing Address - Fax:
Practice Address - Street 1:1223 9TH ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-4349
Practice Address - Country:US
Practice Address - Phone:608-289-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9676-024225100000X
IL070.01551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40469400Medicaid