Healthcare Provider Details

I. General information

NPI: 1609195338
Provider Name (Legal Business Name): CARISSA DEAR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24984 GLASGOW HEIGHTS TER
CHANTILLY VA
20152-3225
US

IV. Provider business mailing address

24984 GLASGOW HEIGHTS TER
CHANTILLY VA
20152-3225
US

V. Phone/Fax

Practice location:
  • Phone: 571-358-7703
  • Fax:
Mailing address:
  • Phone: 571-358-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024168631
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: