Provider Demographics
NPI:1184106023
Name:ADDOTEY, VIVIAN O
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:O
Last Name:ADDOTEY
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 1:9702 GAYTON RD STE 209
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4907
Mailing Address - Country:US
Mailing Address - Phone:804-416-5056
Mailing Address - Fax:804-416-5056
Practice Address - Street 1:1213 BOWDEN RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-5401
Practice Address - Country:US
Practice Address - Phone:804-986-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0707695901251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0707695901Medicaid