Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 2305001920 | VA |
NPI | 1003178583 |
---|---|
Provider Name | Laura Fogle |
First Address | Fort Valley, VA 22652-3208 |
Second Address | Fort Valley, VA 22652-3208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2012 |
Last Update Date | 11/06/2012 |