Basic Information
| Provider Information | |||||||||
| NPI: | 1225576705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONDER | ||||||||
| FirstName: | JANELLE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E VETERANS ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546603105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 E VETERANS ST | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546603105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2017 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502000521 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 0843 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.