Healthcare Provider Details

I. General information

NPI: 1790503258
Provider Name (Legal Business Name): AMIYA CHANEL RATTLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

39 BOXWOOD AVE
WILMINGTON DE
19804-1820
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-3020
  • Fax: 202-476-3091
Mailing address:
  • Phone: 302-310-1269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberPA200001962
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: