Healthcare Provider Details

I. General information

NPI: 1194355388
Provider Name (Legal Business Name): MARYANN VALCOURT CPNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8988 FERN PARK DR
BURKE VA
22015-1635
US

IV. Provider business mailing address

8988 FERN PARK DR
BURKE VA
22015-1635
US

V. Phone/Fax

Practice location:
  • Phone: 703-978-6061
  • Fax: 703-978-0291
Mailing address:
  • Phone: 703-978-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024164946
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: