Provider Demographics
NPI:1366473761
Name:PUMPHREY, MYRA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:LYNN
Last Name:PUMPHREY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 HICKORY PARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-2629
Mailing Address - Country:US
Mailing Address - Phone:804-270-7754
Mailing Address - Fax:
Practice Address - Street 1:5300 HICKORY PARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-2629
Practice Address - Country:US
Practice Address - Phone:804-270-7754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1760434948OtherGROUP NPI