Healthcare Provider Details

I. General information

NPI: 1417623497
Provider Name (Legal Business Name): MALLORY GILES CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20955 PROFESSIONAL PLZ STE 200
ASHBURN VA
20147-3405
US

IV. Provider business mailing address

224-D CORNWALL ST., NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-7652
  • Fax: 703-729-8746
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024182192
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: