Healthcare Provider Details

I. General information

NPI: 1770709073
Provider Name (Legal Business Name): GAYLE S ANDERSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4667 BURNLEY BRANCH LN
BARBOURSVILLE VA
22923-1810
US

IV. Provider business mailing address

4667 BURNLEY BRANCH LN
BARBOURSVILLE VA
22923-1810
US

V. Phone/Fax

Practice location:
  • Phone: 434-973-5792
  • Fax: 434-973-5792
Mailing address:
  • Phone: 434-973-5792
  • Fax: 434-973-5792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2305002349
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: