Healthcare Provider Details

I. General information

NPI: 1841005519
Provider Name (Legal Business Name): FHENIX WEIGHT LOSS FOREVER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
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: 202-715-6624
  • Fax:
Mailing address:
  • Phone: 202-715-6624
  • Fax: 765-680-8654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TISHAMBAY THOMPSON
Title or Position: NP
Credential: FNP
Phone: 703-568-3876