Healthcare Provider Details

I. General information

NPI: 1134751449
Provider Name (Legal Business Name): CYNTHIA B GRESHAM RT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 KEMPSVILLE RD
NORFOLK VA
23502-2205
US

IV. Provider business mailing address

203 CUSTER PLACE
NEWPORT NEWS VA
23608-2619
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-5001
  • Fax:
Mailing address:
  • Phone: 757-288-7710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number0117001487
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: