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General NPI Number Information
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NPI Number | 1225548258
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Entity Type | Individual
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Provider Name | LATIESHA JASMIN CAMACHO PTA
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Gender | Female
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Dates
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Enumeration Date | 10/04/2017
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Last Update Date | 10/04/2017
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Provider Practice Location Address
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Address Line | 14906 JEFFERSON DAVIS HWY
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City | WOODBRIDGE
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State | VA
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Zip | 22191-4016
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Country | US
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Telephone | 703-491-6167
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Fax |
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Provider Business Mailing Address
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Address Line | 10429 SUMMER HILL RD
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-6613
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Country | US
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Telephone | 804-938-3692
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306604855
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License Number State | VA
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