Healthcare Provider Details

I. General information

NPI: 1184438186
Provider Name (Legal Business Name): FHENIX WEIGHT LOSS FOREVER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 LANDOVER RD
CHEVERLY MD
20785-1022
US

IV. Provider business mailing address

13885 HEDGEWOOD DR STE 241
WOODBRIDGE VA
22193-7931
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-6626
  • Fax: 765-680-8654
Mailing address:
  • Phone: 202-715-6626
  • Fax: 765-680-8654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. TISHAMBAY THOMPSON
Title or Position: FNP
Credential: FNP
Phone: 281-770-9577