Healthcare Provider Details

I. General information

NPI: 1790563914
Provider Name (Legal Business Name): YARED TAFFESSE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

IV. Provider business mailing address

708 REDGATE LN
WOODBRIDGE VA
22191-1459
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3400
  • Fax:
Mailing address:
  • Phone: 571-338-8424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC005887
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024188119
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: