Individual
MRS. LYDIAWATI KURNIAWAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
E7404A COUNTY ROAD BB, VIROQUA, WI 54665-7502
(608) 637-5422
Mailing address
821 TAHOE DR, ONALASKA, WI 54650-8234
(608) 779-9008
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
1583-19
WI
Other
Enumeration date
12/07/2011
Last updated
12/07/2011
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