Provider Demographics
NPI:1326671009
Name:LONDON, TICYNN SYMONE
Entity Type:Individual
Prefix:
First Name:TICYNN
Middle Name:SYMONE
Last Name:LONDON
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 1:723 RETRIEVER RUN
Mailing Address - Street 2:TICYNN LONDON
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903
Mailing Address - Country:US
Mailing Address - Phone:757-812-1226
Mailing Address - Fax:
Practice Address - Street 1:723 RETRIEVER RUN
Practice Address - Street 2:TICYNN LONDON
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:757-812-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA612739922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer