Provider Demographics
NPI:1710451497
Name:IWANICKA, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:IWANICKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 BELLEVIEW AVE
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-3004
Practice Address - Country:US
Practice Address - Phone:240-280-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist