Healthcare Provider Details

I. General information

NPI: 1215232772
Provider Name (Legal Business Name): SUBIATU SALMATA WURIE L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4213 WALNEY RD
CHANTILLY VA
20151-2923
US

IV. Provider business mailing address

4213 WALNEY RD
CHANTILLY VA
20151-2923
US

V. Phone/Fax

Practice location:
  • Phone: 703-502-7000
  • Fax: 703-502-7006
Mailing address:
  • Phone: 703-502-7000
  • Fax: 703-502-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002059767
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: