Healthcare Provider Details

I. General information

NPI: 1962973164
Provider Name (Legal Business Name): MARIAN E IDAHOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1054 CASS AVE
WOONSOCKET RI
02895-4935
US

IV. Provider business mailing address

1054 CASS AVENUE
WOONSOCKET RI
02895-5947
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN01982
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN49908
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: