Healthcare Provider Details

I. General information

NPI: 1841740206
Provider Name (Legal Business Name): TIA DENAE KING NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42148 STONE PRESS TER
BRAMBLETON VA
20148-6525
US

IV. Provider business mailing address

42148 STONE PRESS TER
BRAMBLETON VA
20148-6525
US

V. Phone/Fax

Practice location:
  • Phone: 571-210-0640
  • Fax: 844-592-1154
Mailing address:
  • Phone: 571-210-0640
  • Fax: 844-592-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN200247
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN200247
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024190080
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: