Healthcare Provider Details

I. General information

NPI: 1710132972
Provider Name (Legal Business Name): THE PHYSICIAN & MIDWIFE COLLABORATIVE PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE
ALEXANDRIA VA
22304-1313
US

IV. Provider business mailing address

4660 KENMORE AVE
ALEXANDRIA VA
22304-1313
US

V. Phone/Fax

Practice location:
  • Phone: 703-370-4300
  • Fax: 703-370-0044
Mailing address:
  • Phone: 703-370-4300
  • Fax: 703-370-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024169729
License Number StateVA

VIII. Authorized Official

Name: MRS. JULIANN LAZZARO
Title or Position: CERTIFIED NURSE MIDWIFE
Credential: CNM
Phone: 716-912-2945