Healthcare Provider Details

I. General information

NPI: 1710698501
Provider Name (Legal Business Name): MRS. PEARLINE TWILAH-FAYE MUCKELVENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 PRINCE ST FL 2
ALEXANDRIA VA
22314-2818
US

IV. Provider business mailing address

11029 CORVIN PL
WHITE PLAINS MD
20695-4302
US

V. Phone/Fax

Practice location:
  • Phone: 240-302-4043
  • Fax:
Mailing address:
  • Phone: 571-653-7044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019020307
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: