Provider Demographics
NPI:1215308473
Name:KIDOLA, JOAN
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:KIDOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 RED TOP RD
Mailing Address - Street 2:#1
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5907
Mailing Address - Country:US
Mailing Address - Phone:240-595-9416
Mailing Address - Fax:202-541-9845
Practice Address - Street 1:6813 RED TOP RD
Practice Address - Street 2:#1
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-5907
Practice Address - Country:US
Practice Address - Phone:240-595-9416
Practice Address - Fax:202-541-9845
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1006573164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse