Provider Demographics
NPI:1467775007
Name:EGGLESTON, VANESSA MIZELLE (COTA/L)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:MIZELLE
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 SPRUCE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-5814
Mailing Address - Country:US
Mailing Address - Phone:276-632-7146
Mailing Address - Fax:
Practice Address - Street 1:77 SPARTAN CIR
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-2900
Practice Address - Country:US
Practice Address - Phone:276-956-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000083224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant