Healthcare Provider Details

I. General information

NPI: 1265787527
Provider Name (Legal Business Name): DELISA RENE' HORN BRANSON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DELISA RENE' BRANSON LPTA

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 HURT ST SW
ABINGDON VA
24210-3018
US

IV. Provider business mailing address

632 HURT ST SW
ABINGDON VA
24210-3018
US

V. Phone/Fax

Practice location:
  • Phone: 423-213-7318
  • Fax:
Mailing address:
  • Phone: 423-213-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306001094
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0000004417
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: