Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist |
NPI | 1356772305 |
---|---|
Provider Name | Anna Ellesor Gray Detweiler |
First Address | Norfolk, VA 23502-4009 |
Second Address | Norfolk, VA 23502-4009 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2013 |
Last Update Date | 10/01/2014 |