Provider Demographics
NPI:1518670686
Name:PACA, JOANNA KATHRINA REPOLLO (PT)
Entity Type:Individual
Prefix:MS
First Name:JOANNA KATHRINA
Middle Name:REPOLLO
Last Name:PACA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 PELHAM PKWY S APT 6E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1032
Mailing Address - Country:US
Mailing Address - Phone:203-430-4304
Mailing Address - Fax:
Practice Address - Street 1:1150 PELHAM PKWY S APT 6E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1032
Practice Address - Country:US
Practice Address - Phone:203-430-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013378225200000X
NY041207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013378OtherPTA LICENSE
NY041207OtherLICENSE NUMBER