Provider Demographics
NPI:1396295119
Name:PEDULLA, AMY G (DPT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:G
Last Name:PEDULLA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:ANNE
Other - Last Name:GIVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1884 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4934
Mailing Address - Country:US
Mailing Address - Phone:703-534-1352
Mailing Address - Fax:
Practice Address - Street 1:1884 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4934
Practice Address - Country:US
Practice Address - Phone:703-534-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist