Healthcare Provider Details

I. General information

NPI: 1457533655
Provider Name (Legal Business Name): VENILLA R BARNES DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. VENILLA R GIBSON

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COMMERCE DR STE B
FAYETTEVILLE GA
30214-7352
US

IV. Provider business mailing address

105 COMMERCE DR SUITE B
FAYETTEVILLE GA
30214
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-1654
  • Fax: 404-393-4044
Mailing address:
  • Phone: 404-692-1654
  • Fax: 404-393-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305205271
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT009550
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: