Basic Information
| Provider Information | |||||||||
| NPI: | 1922189026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILTIS | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 MAPLE STREET | ||||||||
| Address2: | PO BOX 470 | ||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 3388-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40139200 | 05 | WI | MEDICAID |