Provider Demographics
NPI:1750525895
Name:DUCKETT, DEBORA ANN
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:ANN
Last Name:DUCKETT
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 1:503 CARDINAL CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1758
Mailing Address - Country:US
Mailing Address - Phone:434-572-2007
Mailing Address - Fax:
Practice Address - Street 1:5539 HWY 47
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-3727
Practice Address - Country:US
Practice Address - Phone:434-372-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000664225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-5380Medicaid