Provider Demographics
NPI:1578029807
Name:PITTMAN, TESSA CAMILLE
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:CAMILLE
Last Name:PITTMAN
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 1:1250 MCLIN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:VA
Mailing Address - Zip Code:24281-8275
Mailing Address - Country:US
Mailing Address - Phone:865-585-8595
Mailing Address - Fax:
Practice Address - Street 1:1250 MCLIN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:VA
Practice Address - Zip Code:24281-8275
Practice Address - Country:US
Practice Address - Phone:865-585-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT66419058OtherATHLETIC TRAINING