Healthcare Provider Details

I. General information

NPI: 1952940512
Provider Name (Legal Business Name): ZANNETTA FERGUSON LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HOPE RD STE 215
STAFFORD VA
22554-7287
US

IV. Provider business mailing address

11 HOPE RD STE 215
STAFFORD VA
22554-7287
US

V. Phone/Fax

Practice location:
  • Phone: 866-311-4617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: