Basic Information
| Provider Information | |||||||||
| NPI: | 1255879441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISNIEWSKI | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 NE DALLAS STREET | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986072058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608345055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 740 NE DALLAS ST | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986072058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608345055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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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 | 225100000X | 60717255 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 3774 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.