Healthcare Provider Details

I. General information

NPI: 1619893088
Provider Name (Legal Business Name): MAKAYLA FANNIN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BULIFANTS BLVD STE B
WILLIAMSBURG VA
23188-5731
US

IV. Provider business mailing address

3237 BUCKINGHAM DR
TOANO VA
23168-9455
US

V. Phone/Fax

Practice location:
  • Phone: 757-229-9740
  • Fax: 757-229-9741
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305217670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: