Provider Demographics
NPI:1174551162
Name:KANIUK, MARZENA D (PT)
Entity type:Individual
Prefix:
First Name:MARZENA
Middle Name:D
Last Name:KANIUK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARZENA
Other - Middle Name:D
Other - Last Name:KPUKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3915 30TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:1415 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101
Practice Address - Country:US
Practice Address - Phone:866-644-8040
Practice Address - Fax:630-705-1980
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23691Medicare ID - Type Unspecified
ILQ59854Medicare UPIN