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General NPI Number Information
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NPI Number | 1619588167
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Entity Type | Individual
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Provider Name | KIMBERLY DAWN PHOMSOPHA PTA
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Gender | Female
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Dates
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Enumeration Date | 08/10/2020
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Last Update Date | 08/10/2020
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Provider Practice Location Address
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Address Line | 44124 WOODRIDGE PKWY
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City | LEESBURG
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State | VA
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Zip | 20176-6935
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Country | US
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Telephone | 703-729-4870
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Fax |
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Provider Business Mailing Address
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Address Line | 41269 LOVETTSVILLE RD
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City | LOVETTSVILLE
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State | VA
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Zip | 20180-2310
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Country | US
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Telephone | 703-203-8552
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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 | 2306603910
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License Number State | VA
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