Provider Demographics
NPI:1629196365
Name:MARKS, SALLY ANN (MSED, ATL, ATC)
Entity Type:Individual
Prefix:MISS
First Name:SALLY
Middle Name:ANN
Last Name:MARKS
Suffix:
Gender:F
Credentials:MSED, ATL, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 LAKE CAROLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-5304
Mailing Address - Country:US
Mailing Address - Phone:804-761-8688
Mailing Address - Fax:
Practice Address - Street 1:9414 ATLEE STATION ROAD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2600
Practice Address - Country:US
Practice Address - Phone:804-723-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2017-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260002102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0126000210OtherLICENSE TO PRACTICE