Provider Demographics
NPI:1568638401
Name:NEDRELO, ROXANN KAY (PT)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:KAY
Last Name:NEDRELO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1564
Mailing Address - Country:US
Mailing Address - Phone:715-284-4396
Mailing Address - Fax:715-284-9580
Practice Address - Street 1:1311 TYLER ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1564
Practice Address - Country:US
Practice Address - Phone:715-284-4396
Practice Address - Fax:715-284-9580
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2455-024225100000X
MN4377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40116900Medicaid