Provider Demographics
NPI:1619210465
Name:BANNAN, SUSAN MCALLISTER (LPTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MCALLISTER
Last Name:BANNAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6938 JOCKEY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-2961
Mailing Address - Country:US
Mailing Address - Phone:703-753-5519
Mailing Address - Fax:
Practice Address - Street 1:6938 JOCKEY CLUB LN
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-2961
Practice Address - Country:US
Practice Address - Phone:703-753-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001412225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant