Healthcare Provider Details

I. General information

NPI: 1245025584
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3763 FETTLER PARK DR
DUMFRIES VA
22025-1946
US

IV. Provider business mailing address

950 N GLEBE RD STE 700
ARLINGTON VA
22203-4173
US

V. Phone/Fax

Practice location:
  • Phone: 866-938-9996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLISON HENNESSEY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 304-276-9254