Healthcare Provider Details

I. General information

NPI: 1912380155
Provider Name (Legal Business Name): HANIEH KHORSHIDI BSN, AGNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 RIVER RD STE 4
POTOMAC MD
20854-4907
US

IV. Provider business mailing address

312 WALKER RD
GREAT FALLS VA
22066-3507
US

V. Phone/Fax

Practice location:
  • Phone: 703-400-3866
  • Fax:
Mailing address:
  • Phone: 703-400-3866
  • Fax: 703-671-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024172715
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024172715
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024172715
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: