Provider Demographics
NPI:1992724413
Name:WAMPLER, ELETHIA V
Entity type:Individual
Prefix:
First Name:ELETHIA
Middle Name:V
Last Name:WAMPLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9455 LORTON MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12825 MINNIEVILLE ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-0045
Practice Address - Country:US
Practice Address - Phone:703-971-3701
Practice Address - Fax:301-856-0964
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46950017OtherCAREFIRST NCA
64468701OtherCAREFIRST MARYLAND
64468701OtherCAREFIRST MARYLAND