Provider Demographics
NPI:1912480781
Name:FLEMING-RANDOLPH, VIRGINIA GAYLE (PTA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:GAYLE
Last Name:FLEMING-RANDOLPH
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:PO BOX 2181
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:TX
Mailing Address - Zip Code:78358-2181
Mailing Address - Country:US
Mailing Address - Phone:318-422-6886
Mailing Address - Fax:
Practice Address - Street 1:1008 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3201
Practice Address - Country:US
Practice Address - Phone:361-727-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2070603225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant