Healthcare Provider Details

I. General information

NPI: 1891369757
Provider Name (Legal Business Name): MOLLY FONSECA CHIDDISTER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2021
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 RICHMOND HWY
ALEXANDRIA VA
22306-6647
US

IV. Provider business mailing address

6677 RICHMOND HWY
ALEXANDRIA VA
22306-6647
US

V. Phone/Fax

Practice location:
  • Phone: 703-535-5568
  • Fax:
Mailing address:
  • Phone: 703-535-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0024184307
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number29484
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: