Provider Demographics
NPI:1750845384
Name:WIEDERHOLT, PAMELA JO (DPT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JO
Last Name:WIEDERHOLT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:JO
Other - Last Name:STEIMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 JULIAN AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-4913
Mailing Address - Country:US
Mailing Address - Phone:843-906-7047
Mailing Address - Fax:
Practice Address - Street 1:45-090 NAMOKU ST
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-5305
Practice Address - Country:US
Practice Address - Phone:843-906-7047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist