Healthcare Provider Details

I. General information

NPI: 1174988166
Provider Name (Legal Business Name): VATISHA GAYLE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 POPLAR HILL RD
CHESAPEAKE VA
23321-5515
US

IV. Provider business mailing address

3929 GALLEON DR
CHESAPEAKE VA
23321-3413
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-0050
  • Fax:
Mailing address:
  • Phone: 757-575-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1204019742
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: