Healthcare Provider Details

I. General information

NPI: 1679022420
Provider Name (Legal Business Name): IMANI CASSHAWN CHISLEY-PITTMON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 05/23/2022
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 LANGSTON BLVD
ARLINGTON VA
22207
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-492-3080
  • Fax: 571-492-3081
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR212352
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178077
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: