Provider Demographics
NPI:1477210466
Name:WILKOSZ, ANNEMARIE MIRANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:MIRANDA
Last Name:WILKOSZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12335 RIVERSIDE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3601
Mailing Address - Country:US
Mailing Address - Phone:415-328-0915
Mailing Address - Fax:
Practice Address - Street 1:11460 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6030
Practice Address - Country:US
Practice Address - Phone:310-337-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3012792251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics