Provider Demographics
NPI:1326755307
Name:INSERRA-LE CRONE, RAVENWOLF MOONDRAGON
Entity Type:Individual
Prefix:
First Name:RAVENWOLF
Middle Name:MOONDRAGON
Last Name:INSERRA-LE CRONE
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 1:1515 SHASTA DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6691
Mailing Address - Country:US
Mailing Address - Phone:530-747-7000
Mailing Address - Fax:
Practice Address - Street 1:1515 SHASTA DR
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6691
Practice Address - Country:US
Practice Address - Phone:530-747-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT9712225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant