Healthcare Provider Details

I. General information

NPI: 1326791948
Provider Name (Legal Business Name): MARYANNE ROBERTS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4621 SEMINARY RD APT 201
ALEXANDRIA VA
22304-1400
US

IV. Provider business mailing address

4621 SEMINARY RD APT 201
ALEXANDRIA VA
22304-1400
US

V. Phone/Fax

Practice location:
  • Phone: 703-939-3495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberCN-0010025
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: