Provider Demographics
NPI:1417591660
Name:SQUIRE, THEODORA ANNA
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:ANNA
Last Name:SQUIRE
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 1:2151 OLD BRICK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-5837
Mailing Address - Country:US
Mailing Address - Phone:703-850-8981
Mailing Address - Fax:
Practice Address - Street 1:2151 OLD BRICK RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-5837
Practice Address - Country:US
Practice Address - Phone:703-850-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program