Basic Information
| Provider Information | |||||||||
| NPI: | 1629580402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOMBER | ||||||||
| FirstName: | REANNA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PADDON | ||||||||
| OtherFirstName: | REANNA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2307 HILLSHIRE DR APT 3C | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530815475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627072969 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2017 | ||||||||
| LastUpdateDate: | 11/01/2017 | ||||||||
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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 | 224Z00000X | 5396-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.