Provider Demographics
NPI:1407208192
Name:O'DONNELL, NANCY (LPTA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:O'DONNELL
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5321 STEWART DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-7836
Mailing Address - Country:US
Mailing Address - Phone:757-749-9876
Mailing Address - Fax:
Practice Address - Street 1:6401 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3601
Practice Address - Country:US
Practice Address - Phone:757-420-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant