Healthcare Provider Details

I. General information

NPI: 1184223539
Provider Name (Legal Business Name): MIRNESA TIKVINA MSN, CRNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6355 WALKER LN STE 510
ALEXANDRIA VA
22310-3251
US

IV. Provider business mailing address

6355 WALKER LN STE 510
ALEXANDRIA VA
22310-3251
US

V. Phone/Fax

Practice location:
  • Phone: 703-924-3144
  • Fax:
Mailing address:
  • Phone: 703-924-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001283889
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024185531
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024185531
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: