Healthcare Provider Details

I. General information

NPI: 1205063583
Provider Name (Legal Business Name): CAMILLE MARY LILIANE JANSEN AA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

118 JENNY CT
STRASBURG VA
22657-3789
US

V. Phone/Fax

Practice location:
  • Phone: 301-946-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA000021
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: