Healthcare Provider Details

I. General information

NPI: 1558876235
Provider Name (Legal Business Name): BRIANNA RONDEAU LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 ATWOOD AVE
JOHNSTON RI
02919-3262
US

IV. Provider business mailing address

PO BOX 20372
CRANSTON RI
02920-0944
US

V. Phone/Fax

Practice location:
  • Phone: 401-351-0515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03590
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: