Healthcare Provider Details

I. General information

NPI: 1790408961
Provider Name (Legal Business Name): JACQUELINE KATHY TELLEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WILSON BLVD FL 6
ARLINGTON VA
22209-2281
US

IV. Provider business mailing address

1101 WILSON BLVD FL 6
ARLINGTON VA
22209-2281
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 888-731-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000031726
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024188373
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: