Provider Demographics
NPI:1679634653
Name:NIRIDER, JUANITA LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:LOUISE
Last Name:NIRIDER
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 1:4518 48 ST CT E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98443-2568
Mailing Address - Country:US
Mailing Address - Phone:253-820-4008
Mailing Address - Fax:
Practice Address - Street 1:4518 48 ST CT E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98443-2568
Practice Address - Country:US
Practice Address - Phone:253-820-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000036092251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125743Medicaid