Provider Demographics
NPI:1770262750
Name:SIMS, MARYANNE WIEDENHOEFER (PTA)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:WIEDENHOEFER
Last Name:SIMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RESTON DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-8413
Mailing Address - Country:US
Mailing Address - Phone:757-553-0542
Mailing Address - Fax:
Practice Address - Street 1:140 BRIMLEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-5103
Practice Address - Country:US
Practice Address - Phone:540-752-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606363225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant