Healthcare Provider Details

I. General information

NPI: 1770449035
Provider Name (Legal Business Name): MARISSA RAJA WIEGAND NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43777 CENTRAL STATION DR STE 360
ASHBURN VA
20147-5961
US

IV. Provider business mailing address

2300 TODDSBURY PL
RESTON VA
20191-1623
US

V. Phone/Fax

Practice location:
  • Phone: 703-763-0116
  • Fax:
Mailing address:
  • Phone: 703-401-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024194632
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: