Provider Demographics
NPI:1992534176
Name:ANTU, ROXANNE
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:ANTU
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 1:2037 JERRY MURPHY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1256
Mailing Address - Country:US
Mailing Address - Phone:719-664-6839
Mailing Address - Fax:
Practice Address - Street 1:2037 JERRY MURPHY RD STE 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1256
Practice Address - Country:US
Practice Address - Phone:719-664-6839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist