Provider Demographics
NPI:1124412473
Name:STARK, RONDA (LPTA)
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8715 TIDEWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-5440
Mailing Address - Country:US
Mailing Address - Phone:757-636-9877
Mailing Address - Fax:
Practice Address - Street 1:2405 FORT EUSTIS BLVD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-4163
Practice Address - Country:US
Practice Address - Phone:757-898-3746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601887225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant