Provider Demographics
NPI:1366634230
Name:VANRENSSELAER, VIRGINIA BROOKE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:BROOKE
Last Name:VANRENSSELAER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5820
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-5820
Mailing Address - Country:US
Mailing Address - Phone:804-747-0003
Mailing Address - Fax:
Practice Address - Street 1:3514 MAYLAND CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1421
Practice Address - Country:US
Practice Address - Phone:804-747-0003
Practice Address - Fax:804-747-0043
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist