Healthcare Provider Details

I. General information

NPI: 1932927043
Provider Name (Legal Business Name): EMILY KENDRA FITZGERALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 WAVERLY DR
VIRGINIA BEACH VA
23452-4330
US

IV. Provider business mailing address

2923 SCOTIA DR
CHESAPEAKE VA
23325-3525
US

V. Phone/Fax

Practice location:
  • Phone: 757-450-0383
  • Fax:
Mailing address:
  • Phone: 425-387-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-378263
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: