Provider Demographics
NPI:1720425549
Name:WAASDORP, ILANA NICOLE KELLOGG (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:NICOLE KELLOGG
Last Name:WAASDORP
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-5204
Mailing Address - Country:US
Mailing Address - Phone:303-900-3457
Mailing Address - Fax:
Practice Address - Street 1:1421 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5204
Practice Address - Country:US
Practice Address - Phone:303-900-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012174225100000X
VA23052129412251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist