Basic Information
| Provider Information | |||||||||
| NPI: | 1437417755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDEIROS | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| OtherLastName: | NANNIG | ||||||||
| OtherFirstName: | JADE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 RICHMOND SQ STE 200 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029065117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014334172 | ||||||||
| FaxNumber: | 4014330612 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017267100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 02463 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.