Provider Demographics
NPI:1710648308
Name:FISHBURN, ESTIE
Entity Type:Individual
Prefix:
First Name:ESTIE
Middle Name:
Last Name:FISHBURN
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 1:567 WATERS RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-7300
Mailing Address - Country:US
Mailing Address - Phone:301-785-6650
Mailing Address - Fax:
Practice Address - Street 1:100 ANNA GOODE WAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-9236
Practice Address - Country:US
Practice Address - Phone:301-785-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606044225200000X
MDA3497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant