Provider Demographics
NPI:1174988166
Name:HARRIS, VATISHA GAYLE
Entity type:Individual
Prefix:
First Name:VATISHA
Middle Name:GAYLE
Last Name:HARRIS
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 1:3929 GALLEON DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3413
Mailing Address - Country:US
Mailing Address - Phone:757-575-8311
Mailing Address - Fax:
Practice Address - Street 1:3933 POPLAR HILL RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5515
Practice Address - Country:US
Practice Address - Phone:757-483-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12040197421744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management