Healthcare Provider Details

I. General information

NPI: 1265681332
Provider Name (Legal Business Name): JA'NAI XZANA TELLIS FREDERICK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 IRON BRIDGE RD
CHESTERFIELD VA
23832-6601
US

IV. Provider business mailing address

PO BOX 1118
CHESTERFIELD VA
23832-9123
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4877
  • Fax: 804-796-9168
Mailing address:
  • Phone: 804-748-4877
  • Fax: 804-796-9168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001758
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: