Provider Demographics
NPI:1144322256
Name:WIESNER, PATRICIA (PT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-0591
Mailing Address - Country:US
Mailing Address - Phone:618-632-9120
Mailing Address - Fax:618-551-2697
Practice Address - Street 1:1567 SINKING SPRINGS DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6658
Practice Address - Country:US
Practice Address - Phone:618-632-9120
Practice Address - Fax:618-551-2697
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070003265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist