Healthcare Provider Details

I. General information

NPI: 1114330024
Provider Name (Legal Business Name): MICHELLE BYRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 0DARA DR APT 307
FOREST VA
24551
US

IV. Provider business mailing address

140 0DARA DR APT 307
FOREST VA
24551
US

V. Phone/Fax

Practice location:
  • Phone: 910-584-4419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306603594
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: