Healthcare Provider Details

I. General information

NPI: 1285414540
Provider Name (Legal Business Name): KEALAN WINTERS FAERBER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEALAN WINTERS JEWELL

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROMANO VINEYARD WAY STE 120
NORTH KINGSTOWN RI
02852-8428
US

IV. Provider business mailing address

46 ISLAND DR
MIDDLETOWN RI
02842-7508
US

V. Phone/Fax

Practice location:
  • Phone: 401-268-6400
  • Fax:
Mailing address:
  • Phone: 401-684-4686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA00724
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: