Provider Demographics
NPI:1356772305
Name:DETWEILER, ANNA ELLESOR GRAY (CPO)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:ELLESOR GRAY
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 N CENTER DR
Mailing Address - Street 2:BLDG 15 SUITE 201
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4009
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:757-892-5303
Practice Address - Street 1:6320 N CENTER DR
Practice Address - Street 2:BLDG 15 SUITE 201
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4009
Practice Address - Country:US
Practice Address - Phone:757-892-5300
Practice Address - Fax:757-892-5303
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist