Provider Demographics
NPI:1144078734
Name:KOON, EVELYN ANN (DPT)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:ANN
Last Name:KOON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:4710 PUDDLEDOCK RD STE 100
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1269
Practice Address - Country:US
Practice Address - Phone:804-732-0095
Practice Address - Fax:804-732-0045
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist