Healthcare Provider Details

I. General information

NPI: 1063760130
Provider Name (Legal Business Name): VIRGINIA L PAINE RD, CDOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WARREN AVE STE 100
EAST PROVIDENCE RI
02914-1430
US

IV. Provider business mailing address

163 GOLD MINE RD
CHEPACHET RI
02814-1758
US

V. Phone/Fax

Practice location:
  • Phone: 401-383-9662
  • Fax: 401-383-6526
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN18730
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberRN18730
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: