Provider Demographics
NPI:1699953208
Name:BREISTER, LYNNE MARIE (PT)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:MARIE
Last Name:BREISTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11609 E MINNESUING RD
Mailing Address - Street 2:
Mailing Address - City:LAKE NEBAGAMON
Mailing Address - State:WI
Mailing Address - Zip Code:54849-9157
Mailing Address - Country:US
Mailing Address - Phone:715-374-2021
Mailing Address - Fax:715-374-2355
Practice Address - Street 1:11609 E MINNESUING RD
Practice Address - Street 2:
Practice Address - City:LAKE NEBAGAMON
Practice Address - State:WI
Practice Address - Zip Code:54849-9157
Practice Address - Country:US
Practice Address - Phone:715-374-2021
Practice Address - Fax:715-374-2355
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3988-24225100000X
MN4733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist