Provider Demographics
NPI:1083171789
Name:CYROCKI, ANNETTE SUSAN
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:SUSAN
Last Name:CYROCKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27574 2900 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA MOILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61330-9514
Mailing Address - Country:US
Mailing Address - Phone:815-866-1717
Mailing Address - Fax:
Practice Address - Street 1:27574 2900 NORTH AVE
Practice Address - Street 2:
Practice Address - City:LA MOILLE
Practice Address - State:IL
Practice Address - Zip Code:61330-9514
Practice Address - Country:US
Practice Address - Phone:815-866-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004522225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant