Healthcare Provider Details

I. General information

NPI: 1114559804
Provider Name (Legal Business Name): EMILY BROOKE WARRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 SANDY RIVER RD
AXTON VA
24054-2761
US

IV. Provider business mailing address

2696 GREENSBORO RD
MARTINSVILLE VA
24112-8106
US

V. Phone/Fax

Practice location:
  • Phone: 276-340-7027
  • Fax:
Mailing address:
  • Phone: 276-638-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-007720
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: