Healthcare Provider Details

I. General information

NPI: 1477658417
Provider Name (Legal Business Name): RENEE HAYNESWORTH, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20608 GORDON PARK SQ SUITE 170
ASHBURN VA
20147-3141
US

IV. Provider business mailing address

PO BOX 495
ASHBURN VA
20146-0495
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-2424
  • Fax: 703-858-7048
Mailing address:
  • Phone: 703-858-2424
  • Fax: 703-858-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101102656
License Number StateVA

VIII. Authorized Official

Name: DR. RENEE HAYNESWORTH
Title or Position: OWNER
Credential: M.D.
Phone: 703-858-2424