Provider Demographics
NPI:1992489397
Name:VERNON, ELENI GLORIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELENI
Middle Name:GLORIA
Last Name:VERNON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 PEACH TREE DR NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-2028
Mailing Address - Country:US
Mailing Address - Phone:703-839-5533
Mailing Address - Fax:
Practice Address - Street 1:4808 PEACH TREE DR NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2028
Practice Address - Country:US
Practice Address - Phone:703-839-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist