Provider Demographics
NPI:1417306069
Name:RIDDELL, JOHANNA (PTA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-3143
Mailing Address - Country:US
Mailing Address - Phone:360-293-7137
Mailing Address - Fax:
Practice Address - Street 1:1300 O AVE
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2187
Practice Address - Country:US
Practice Address - Phone:360-419-4699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160259921172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker