Healthcare Provider Details

I. General information

NPI: 1114919453
Provider Name (Legal Business Name): WENDOLINE A PROFFITT P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

IV. Provider business mailing address

112 CANDLEWOOD CT
LYNCHBURG VA
24502-2653
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-5032
  • Fax:
Mailing address:
  • Phone: 434-832-0591
  • Fax: 434-832-0682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305003521
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: