Provider Demographics
NPI:1891088647
Name:ANNEN, STEPHANIE RENNE (DPT, C/NDT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENNE
Last Name:ANNEN
Suffix:
Gender:F
Credentials:DPT, C/NDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1486 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3268
Mailing Address - Country:US
Mailing Address - Phone:262-247-8030
Mailing Address - Fax:262-241-8304
Practice Address - Street 1:1486 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3268
Practice Address - Country:US
Practice Address - Phone:262-247-8030
Practice Address - Fax:262-241-8304
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11690-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078897Medicaid