Provider Demographics
NPI:1053705038
Name:O'DONNELL, MANDE
Entity type:Individual
Prefix:
First Name:MANDE
Middle Name:
Last Name:O'DONNELL
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 1:935 BATTLEFIELD BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:VA
Mailing Address - Zip Code:22844-2059
Mailing Address - Country:US
Mailing Address - Phone:540-740-3314
Mailing Address - Fax:
Practice Address - Street 1:935 BATTLEFIELD BLUFF DR
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:VA
Practice Address - Zip Code:22844-2059
Practice Address - Country:US
Practice Address - Phone:540-740-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603968225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant