MEDICARE: FANNYPANTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	1329638	VA

General Provider Information

NPI Number	:	1841628138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FANNYPANTS LLC

Provider Business Mailing Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1150
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	SUITE 1150
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	703-953-3099
Fax Number	:	703-956-6020

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	SOPHIA PARKER
Credential	:
Telephone Number	:	703-953-3099

Provider Enumeration Date	:	10/23/2013
Last Update Date	:	10/23/2013

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Directions to “FANNYPANTS LLC ” Practice Location

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