Healthcare Provider Details

I. General information

NPI: 1164143871
Provider Name (Legal Business Name): MS. ROSE MUDIDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W BRADDOCK RD
ALEXANDRIA VA
22304-1099
US

IV. Provider business mailing address

4400 W BRADDOCK RD
ALEXANDRIA VA
22304-1010
US

V. Phone/Fax

Practice location:
  • Phone: 703-379-6000
  • Fax: 703-671-8897
Mailing address:
  • Phone: 703-379-6000
  • Fax: 703-671-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberH1871
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: