Healthcare Provider Details

I. General information

NPI: 1093428120
Provider Name (Legal Business Name): CERENA ICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9346 OAK AVE
WACONIA MN
55387-9422
US

IV. Provider business mailing address

9346 OAK AVE
WACONIA MN
55387-9422
US

V. Phone/Fax

Practice location:
  • Phone: 952-223-2506
  • Fax:
Mailing address:
  • Phone: 952-223-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: