Provider Demographics
NPI:1194734558
Name:CRANE, ROSEANNA CAROL (LAC)
Entity type:Individual
Prefix:MS
First Name:ROSEANNA
Middle Name:CAROL
Last Name:CRANE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1814
Mailing Address - Country:US
Mailing Address - Phone:415-460-6504
Mailing Address - Fax:415-552-0416
Practice Address - Street 1:700 E ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2762
Practice Address - Country:US
Practice Address - Phone:415-256-1934
Practice Address - Fax:415-256-1934
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5384171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0053840Medicaid