Provider Demographics
NPI:1487953592
Name:GAGNON, TAMMY LUELLA (PTA)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LUELLA
Last Name:GAGNON
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 1:932 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEKOOSA
Mailing Address - State:WI
Mailing Address - Zip Code:54457-1075
Mailing Address - Country:US
Mailing Address - Phone:715-886-2973
Mailing Address - Fax:
Practice Address - Street 1:W6990 S SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5890
Practice Address - Country:US
Practice Address - Phone:920-787-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1129-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant