Healthcare Provider Details

I. General information

NPI: 1952463606
Provider Name (Legal Business Name): DOMINION FAMILY HEALTH, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MAPLEDALE PLZ
DALE CITY VA
22193-4535
US

IV. Provider business mailing address

5800 MAPLEDALE PLZ
DALE CITY VA
22193-4535
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-0067
  • Fax: 703-670-0301
Mailing address:
  • Phone: 703-670-0067
  • Fax: 703-670-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101226862
License Number StateVA

VIII. Authorized Official

Name: LISA KIMBERLY MALLOY
Title or Position: OWNER
Credential: MD
Phone: 703-670-0067