Healthcare Provider Details

I. General information

NPI: 1699399147
Provider Name (Legal Business Name): JESSIE ANDOSCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CRANSTON ST
CRANSTON RI
02920-5038
US

IV. Provider business mailing address

1700 CRANSTON ST
CRANSTON RI
02920-5038
US

V. Phone/Fax

Practice location:
  • Phone: 401-223-0230
  • Fax:
Mailing address:
  • Phone: 401-223-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA01271
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: