Provider Demographics
NPI:1053573030
Name:FJELSTAD, ELIZABETH G (DPT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:G
Last Name:FJELSTAD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:G
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1970 NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8890
Mailing Address - Country:US
Mailing Address - Phone:715-420-0728
Mailing Address - Fax:715-420-0729
Practice Address - Street 1:1970 NAVAJO ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-8890
Practice Address - Country:US
Practice Address - Phone:715-420-0728
Practice Address - Fax:715-420-0729
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36182600Medicaid