Provider Demographics
NPI:1043238215
Name:FLEETWOOD, PHYLLIS ANN (PT,MS,OCS)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ANN
Last Name:FLEETWOOD
Suffix:
Gender:F
Credentials:PT,MS,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42660 LEGACY PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6956
Mailing Address - Country:US
Mailing Address - Phone:703-327-5193
Mailing Address - Fax:
Practice Address - Street 1:500 MONTGOMERY ST STE 400
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1560
Practice Address - Country:US
Practice Address - Phone:703-548-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA014345P87Medicare PIN