Provider Demographics
NPI:1942501259
Name:FISHER, MANDY ANTOINETTE
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:ANTOINETTE
Last Name:FISHER
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 1:1545 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-5017
Mailing Address - Country:US
Mailing Address - Phone:724-984-8664
Mailing Address - Fax:
Practice Address - Street 1:1545 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-5017
Practice Address - Country:US
Practice Address - Phone:724-984-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204274225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist