Healthcare Provider Details

I. General information

NPI: 1366634230
Provider Name (Legal Business Name): VIRGINIA BROOKE VANRENSSELAER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 MAYLAND CT
RICHMOND VA
23233-1421
US

IV. Provider business mailing address

PO BOX 5820
GLEN ALLEN VA
23058-5820
US

V. Phone/Fax

Practice location:
  • Phone: 804-747-0003
  • Fax: 804-747-0043
Mailing address:
  • Phone: 804-747-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2305205118
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: