Provider Demographics
NPI:1598032955
Name:SUMMERRISE, ANN MARIE (IDMT)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:SUMMERRISE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CHIPPENHAM DR APT H
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-2843
Mailing Address - Country:US
Mailing Address - Phone:210-568-7135
Mailing Address - Fax:
Practice Address - Street 1:102 CHIPPENHAM DR APT H
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-2843
Practice Address - Country:US
Practice Address - Phone:210-568-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians