Healthcare Provider Details

I. General information

NPI: 1063171288
Provider Name (Legal Business Name): CLARISSA MAGORI GANDOLFO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD SUITE S207
BETHESDA MD
20816
US

IV. Provider business mailing address

6010 OVERLEA RD
BETHESDA MD
20816
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN200001817
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: