Healthcare Provider Details

I. General information

NPI: 1457690794
Provider Name (Legal Business Name): PATRICIA ANN WILBURN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BEN BOLT AVE
TAZEWELL VA
24651-9703
US

IV. Provider business mailing address

207 VALLEYVIEW ST
N TAZEWELL VA
24630-9585
US

V. Phone/Fax

Practice location:
  • Phone: 276-988-2515
  • Fax:
Mailing address:
  • Phone: 276-979-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number23056001441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: