Provider Demographics
NPI:1871958827
Name:CRUCIANI, ROXANNE MARIE (PTA)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:MARIE
Last Name:CRUCIANI
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 1:23443 JOHN NELSON RD
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-8462
Mailing Address - Country:US
Mailing Address - Phone:612-986-1738
Mailing Address - Fax:
Practice Address - Street 1:41 EAST COUNTY ROAD C, #211
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117
Practice Address - Country:US
Practice Address - Phone:612-986-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1317225200000X
WI2928-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant