Healthcare Provider Details

I. General information

NPI: 1992541890
Provider Name (Legal Business Name): CHANTILLY WELLNESS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200A TECHNOLOGY CT
CHANTILLY VA
20151-1214
US

IV. Provider business mailing address

4200A TECHNOLOGY CT
CHANTILLY VA
20151-1214
US

V. Phone/Fax

Practice location:
  • Phone: 540-709-1737
  • Fax: 866-611-3615
Mailing address:
  • Phone: 540-709-1737
  • Fax: 866-611-3615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. EMILY DEROCCO
Title or Position: SECRETARY
Credential: DC
Phone: 620-504-2434