Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 0101243771 | VA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 0101243771 | VA |
N | 207QS0010X | Family Doctor - Sports Medicine | 0101243771 | VA |
NPI | 1366414385 |
---|---|
Provider Name | Phyllis Blattstain Montellese |
First Address | Palmyra, VA 22963-4381 |
Second Address | Palmyra, VA 22963 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2006 |
Last Update Date | 06/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B41200 | (02) |