Healthcare Provider Details

I. General information

NPI: 1588122857
Provider Name (Legal Business Name): MARY GERALDINE GAINES LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 MEADOWVIEW DR STE 5
DANVILLE VA
24541-7352
US

IV. Provider business mailing address

1555 MEADOWVIEW DR STE 5
DANVILLE VA
24541-7352
US

V. Phone/Fax

Practice location:
  • Phone: 434-685-1570
  • Fax: 434-685-1477
Mailing address:
  • Phone: 434-685-1570
  • Fax: 434-685-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002024332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: