Provider Demographics
NPI:1710522529
Name:FAIRHEART, TRACI J (DPT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:J
Last Name:FAIRHEART
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:5388 DISCOVERY PARK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8218
Mailing Address - Country:US
Mailing Address - Phone:757-707-3955
Mailing Address - Fax:757-603-6231
Practice Address - Street 1:201 BULIFANTS BLVD STE B
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5731
Practice Address - Country:US
Practice Address - Phone:757-229-9740
Practice Address - Fax:757-229-9741
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist