Provider Demographics
NPI:1437662996
Name:FIZZANO, ANDREA TENNILLE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:TENNILLE
Last Name:FIZZANO
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 1:1980 ANGLE PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-5634
Mailing Address - Country:US
Mailing Address - Phone:276-340-6345
Mailing Address - Fax:
Practice Address - Street 1:25 BERNARD RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-6614
Practice Address - Country:US
Practice Address - Phone:540-483-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005078225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist