Healthcare Provider Details

I. General information

NPI: 1396295119
Provider Name (Legal Business Name): AMY G PEDULLA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY ANNE GIVEN DPT

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 VIRGINIA AVE
MC LEAN VA
22101-4934
US

IV. Provider business mailing address

1884 VIRGINIA AVE
MC LEAN VA
22101-4934
US

V. Phone/Fax

Practice location:
  • Phone: 703-534-1352
  • Fax:
Mailing address:
  • Phone: 703-534-1352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305209992
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: