Healthcare Provider Details

I. General information

NPI: 1699284802
Provider Name (Legal Business Name): WYATT EZARA GREENE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22556 AMENDOLA TER STE 150
ASHBURN VA
20148-2413
US

IV. Provider business mailing address

1100 CIRCLE 75 PKWY SE STE 1400
ATLANTA GA
30339-3067
US

V. Phone/Fax

Practice location:
  • Phone: 571-465-9289
  • Fax: 571-465-9297
Mailing address:
  • Phone: 678-981-3543
  • Fax: 404-777-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305211504
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: