Provider Demographics
NPI:1023129434
Name:HERNDON, PHYLLIS JANE (RPT)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:JANE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HARPER LN
Mailing Address - Street 2:
Mailing Address - City:BLAIRS
Mailing Address - State:VA
Mailing Address - Zip Code:24527-1005
Mailing Address - Country:US
Mailing Address - Phone:434-203-0578
Mailing Address - Fax:
Practice Address - Street 1:300 BLUE RIDGE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-7261
Practice Address - Country:US
Practice Address - Phone:276-632-1249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist