Provider Demographics
NPI:1184741571
Name:MARANDOLA-WILSON, JOANNA MARIA (PT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:MARIA
Last Name:MARANDOLA-WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:MARIA
Other - Last Name:MARANDOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 20372
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-0944
Mailing Address - Country:US
Mailing Address - Phone:401-785-1016
Mailing Address - Fax:401-785-1018
Practice Address - Street 1:1100 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-5121
Practice Address - Country:US
Practice Address - Phone:401-785-1016
Practice Address - Fax:401-785-1018
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT00675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT00675OtherSTATE LICENSE NUMBER