Healthcare Provider Details

I. General information

NPI: 1962763599
Provider Name (Legal Business Name): VICTORINE CHANTAL N NJILA DEBALOU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20116 ASHBROOK PL STE 100
ASHBURN VA
20147-3445
US

IV. Provider business mailing address

20116 ASHBROOK PL STE 100
ASHBURN VA
20147-3445
US

V. Phone/Fax

Practice location:
  • Phone: 571-291-9752
  • Fax:
Mailing address:
  • Phone: 517-291-9752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: