Basic Information
| Provider Information | |||||||||
| NPI: | 1861740433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 S HOLMEN DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | HOLMEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546369468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085269888 | ||||||||
| FaxNumber: | 6085269965 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 W BREWSTER ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549146444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208321657 | ||||||||
| FaxNumber: | 9209684153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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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 | 11969-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11969-24 | 01 | WI | PT LICENSE | OTHER |