MEDICARE: MS. ANTIONETTE BALLARD QDDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1629083373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANTIONETTE BALLARD QDDP

Provider Business Mailing Address
First Line	:	1216 E LITTLE CREEK RD
Second Line	:	SUITE 303
City	:	NORFOLK
State	:	VA
Zip	:	23518-3900
Country	:	US
Telephone Number	:	757-289-5946
Fax Number	:	757-480-0528

Provider Business Practice Location Address
First Line	:	1216 E LITTLE CREEK RD
Second Line	:	SUITE 303
City	:	NORFOLK
State	:	VA
Zip	:	23518-3900
Country	:	US
Telephone Number	:	757-289-5946
Fax Number	:	757-480-0528

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/09/2007

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