Healthcare Provider Details

I. General information

NPI: 1295409092
Provider Name (Legal Business Name): MALLOREE DIANNE ESCUE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43330 JUNCTION PLZ STE 122
ASHBURN VA
20147-3407
US

IV. Provider business mailing address

13175 MARINA WAY APT 356
WOODBRIDGE VA
22191-1266
US

V. Phone/Fax

Practice location:
  • Phone: 703-972-1040
  • Fax:
Mailing address:
  • Phone: 407-756-8376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305214542
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: