Provider Demographics
NPI:1528525805
Name:VANWIEL, LISA MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:VANWIEL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 JERSEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-3737
Mailing Address - Country:US
Mailing Address - Phone:515-491-7865
Mailing Address - Fax:
Practice Address - Street 1:2350 OAKDALE BLVD
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9702
Practice Address - Country:US
Practice Address - Phone:515-491-7865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA094540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist