Healthcare Provider Details

I. General information

NPI: 1275063620
Provider Name (Legal Business Name): JEANNETTE LYNN KIKUCHI CO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANNETTE LYNN GUARRIELLO CO

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ALPHA DR
PITTSBURGH PA
15238-2908
US

IV. Provider business mailing address

3955 BIGELOW BLVD APT 905
PITTSBURGH PA
15213-1238
US

V. Phone/Fax

Practice location:
  • Phone: 412-477-1405
  • Fax:
Mailing address:
  • Phone: 301-580-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOH000308
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: