Provider Demographics
NPI:1528501053
Name:KISTNER, LAURA (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KISTNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 HARBOR VIEW RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7020
Mailing Address - Country:US
Mailing Address - Phone:715-577-3373
Mailing Address - Fax:
Practice Address - Street 1:2231 US HIGHWAY 12 STE 201
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-3270
Practice Address - Country:US
Practice Address - Phone:715-684-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11905-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist