Basic Information
| Provider Information | |||||||||
| NPI: | 1730660291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERTIN | ||||||||
| FirstName: | STEPHANIA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FIANNA WAY | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729193872 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 4794782516 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543033214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204995177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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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 | 14408-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.