Basic Information
Provider Information
NPI: 1003005414
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VICENTE
FirstName: JOAN
MiddleName: LUNA
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4560 SE INTERNATIONAL WAY
Address2: CONSONUS HEALTHCARE SERVICES SUITE 100
City: MILWAUKIE
State: OR
PostalCode: 97222
CountryCode: US
TelephoneNumber: 9712065149
FaxNumber: 9712065209
Practice Location
Address1: 4560 SE INTERNATIONAL WAY
Address2: CONSONUS HEALTHCARE SERVICES SUITE 100
City: MILWAUKIE
State: OR
PostalCode: 97222
CountryCode: US
TelephoneNumber: 9712065149
FaxNumber: 9712065209
Other Information
ProviderEnumerationDate: 10/22/2007
LastUpdateDate: 10/22/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X5501012517MIN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X33804CAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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