Provider Demographics
NPI:1447351564
Name:SUMMERILL, TANIELLE (PTA)
Entity type:Individual
Prefix:
First Name:TANIELLE
Middle Name:
Last Name:SUMMERILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 N 111TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4111
Mailing Address - Country:US
Mailing Address - Phone:414-476-2304
Mailing Address - Fax:
Practice Address - Street 1:2626 N WAUWATOSA AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1137
Practice Address - Country:US
Practice Address - Phone:414-774-7794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI990-019225200000X
IDPTA-300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40459000Medicaid