Provider Demographics
NPI:1720745193
Name:FUERSTENBERG, TAYLOR ANN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANN
Last Name:FUERSTENBERG
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6275 W MORRIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9352
Mailing Address - Country:US
Mailing Address - Phone:262-751-7644
Mailing Address - Fax:
Practice Address - Street 1:N70W23407 PRIDES RD
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3274
Practice Address - Country:US
Practice Address - Phone:262-751-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-9212255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer