Provider Demographics
NPI:1316675580
Name:FODDRELL, JULIAN
Entity type:Individual
Prefix:MR
First Name:JULIAN
Middle Name:
Last Name:FODDRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 ALAN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-7717
Mailing Address - Country:US
Mailing Address - Phone:276-288-4638
Mailing Address - Fax:
Practice Address - Street 1:707 N ELM ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3917
Practice Address - Country:US
Practice Address - Phone:336-885-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606072225200000X
NCCP012054A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant