Healthcare Provider Details

I. General information

NPI: 1477003853
Provider Name (Legal Business Name): CARLY C WESTBROOK PA-S, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 E WEST RD
MIDLOTHIAN VA
23114-3372
US

IV. Provider business mailing address

825 FAIRFAX AVE
NORFOLK VA
23507-1912
US

V. Phone/Fax

Practice location:
  • Phone: 804-379-2414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: