Provider Demographics
NPI:1699184531
Name:PIENIADZ, JEDIDIAH
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:
Last Name:PIENIADZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9923 HANNETT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4042
Mailing Address - Country:US
Mailing Address - Phone:505-363-0921
Mailing Address - Fax:
Practice Address - Street 1:9923 HANNETT AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4042
Practice Address - Country:US
Practice Address - Phone:505-363-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3222224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant