Healthcare Provider Details

I. General information

NPI: 1366084931
Provider Name (Legal Business Name): DIANA CHANGANAQUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 RICHMOND HWY
ALEXANDRIA VA
22306-6647
US

IV. Provider business mailing address

8327 BLUEBIRD WAY UNIT H
LORTON VA
22079-2847
US

V. Phone/Fax

Practice location:
  • Phone: 703-535-5568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402207810
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: