Basic Information
| Provider Information | |||||||||
| NPI: | 1164998225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POOLER | ||||||||
| FirstName: | CHEYENNE | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67225 ORLOWSKI RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548474709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152790622 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 14TH ST | ||||||||
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| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2018 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.