Healthcare Provider Details

I. General information

NPI: 1750298642
Provider Name (Legal Business Name): MRS. FATEMEH AVAZZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42904 RIDGEWAY DR
BROADLANDS VA
20148-4551
US

IV. Provider business mailing address

42904 RIDGEWAY DR
BROADLANDS VA
20148-4551
US

V. Phone/Fax

Practice location:
  • Phone: 571-201-0814
  • Fax:
Mailing address:
  • Phone: 571-201-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH200005313
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: