Healthcare Provider Details

I. General information

NPI: 1518776889
Provider Name (Legal Business Name): MIA LAUREN FELLOWS AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

475 ONEIDA ST APT 1
PITTSBURGH PA
15211-1219
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-6500
  • Fax:
Mailing address:
  • Phone: 412-926-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP200024044
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: