Healthcare Provider Details

I. General information

NPI: 1760555627
Provider Name (Legal Business Name): CONCEPCION MUNGCAL BALATBAT R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 BEACON HILL RD
ALEXANDRIA VA
22306-1611
US

IV. Provider business mailing address

8531 HOOES RD
SPRINGFIELD VA
22153-1709
US

V. Phone/Fax

Practice location:
  • Phone: 703-660-6440
  • Fax: 703-660-8947
Mailing address:
  • Phone: 703-644-0916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0001162249
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: