Healthcare Provider Details

I. General information

NPI: 1437823242
Provider Name (Legal Business Name): AUTUMN BROOKE PRESCOTT CNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 CENTREVILLE RD STE 101
CHANTILLY VA
20151-3289
US

IV. Provider business mailing address

12178 CHESHIRE CT
BRISTOW VA
20136-2409
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-8600
  • Fax:
Mailing address:
  • Phone: 804-314-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024182289
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: