Provider Demographics
NPI:1275910309
Name:DILLARD, CHANNON (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:CHANNON
Middle Name:
Last Name:DILLARD
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 KECOUGHTAN RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-3505
Mailing Address - Country:US
Mailing Address - Phone:757-650-6948
Mailing Address - Fax:
Practice Address - Street 1:3403 KECOUGHTAN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-3505
Practice Address - Country:US
Practice Address - Phone:757-650-6948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603960225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant