Healthcare Provider Details

I. General information

NPI: 1053692343
Provider Name (Legal Business Name): TRACI ANNETTA MARIN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24430 STONE SPRINGS BLVD., SUITE 475
DULLES VA
20166-2272
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-957-1245
  • Fax:
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-830-4188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024169463
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: