Healthcare Provider Details

I. General information

NPI: 1417686726
Provider Name (Legal Business Name): NANA ABENA AGO BOATENG OTD, R/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N LEE ST FL 3
ALEXANDRIA VA
22314-2631
US

IV. Provider business mailing address

7782 ROTHERHAM DR
HANOVER MD
21076-1460
US

V. Phone/Fax

Practice location:
  • Phone: 703-299-0051
  • Fax:
Mailing address:
  • Phone: 443-410-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number118820-2026
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: