Healthcare Provider Details

I. General information

NPI: 1699890400
Provider Name (Legal Business Name): SIRRON MARION WARE COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 BATTLEFIELD BLVD N STE 103
CHESAPEAKE VA
23320-4791
US

IV. Provider business mailing address

4136 BISHOPS PL
PORTSMOUTH VA
23703-5501
US

V. Phone/Fax

Practice location:
  • Phone: 757-549-1088
  • Fax:
Mailing address:
  • Phone: 757-484-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1201103199
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: