Provider Demographics
NPI:1689954323
Name:CANNARIATO, STACY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:CANNARIATO
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 1:13706 W FERGUSON RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-2512
Mailing Address - Country:US
Mailing Address - Phone:262-794-3318
Mailing Address - Fax:
Practice Address - Street 1:5700 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1442
Practice Address - Country:US
Practice Address - Phone:414-423-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4919-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist