Basic Information
| Provider Information | |||||||||
| NPI: | 1750412268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | FERNANDA | ||||||||
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| Credential: | PT DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SMITHFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028603497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017259666 | ||||||||
| FaxNumber: | 4017225896 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SMITHFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028603497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017259666 | ||||||||
| FaxNumber: | 4017225896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT01869 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 4695 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 411571 | 01 | BLUE CROSS BS | OTHER |