Individual
ELLEN M WANTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LAT
Contact information
Practice address
N63 W23075 HWY 74, SUSSEX, WI 53089
(414) 566-4582
Mailing address
2858 S 95TH ST, WEST ALLIS, WI 53227-3306
(414) 350-3416
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
69-039
WI
Other
Enumeration date
01/05/2007
Last updated
07/08/2007
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