Healthcare Provider Details

I. General information

NPI: 1346219169
Provider Name (Legal Business Name): JENNIFER M WALSH RN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N BEAUREGARD ST STE 200
ALEXANDRIA VA
22311-1700
US

IV. Provider business mailing address

1707 OSAGE ST ALEXANDRIA LAKE RIDGE PEDIATRICS STE 104
ALEXANDRIA VA
22302
US

V. Phone/Fax

Practice location:
  • Phone: 703-231-9059
  • Fax: 703-212-6606
Mailing address:
  • Phone: 703-212-6600
  • Fax: 703-931-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024157708
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberPNP0024157708
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: