Provider Demographics
NPI:1932779139
Name:WILLIQUETTE, ANGELA LEE (PTA)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:LEE
Last Name:WILLIQUETTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 14TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5857
Mailing Address - Country:US
Mailing Address - Phone:920-475-7852
Mailing Address - Fax:
Practice Address - Street 1:265 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5334
Practice Address - Country:US
Practice Address - Phone:920-922-7342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI-Medicaid