Basic Information
| Provider Information | |||||||||
| NPI: | 1831865302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNIG | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10355 W PLUM TREE CIR APT 201 | ||||||||
| Address2: | |||||||||
| City: | HALES CORNERS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531302634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146141244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6263 N GREEN BAY AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532093823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143510543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2021 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 314319 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 314319 | 01 | WI | PHYSICAL THERAPIST ASSISTANT | OTHER |