Healthcare Provider Details

I. General information

NPI: 1386551505
Provider Name (Legal Business Name): MINA BULATOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17345 HARRISON RIDGE DR
DUMFRIES VA
22026-2869
US

IV. Provider business mailing address

17345 HARRISON RIDGE DR
DUMFRIES VA
22026-2869
US

V. Phone/Fax

Practice location:
  • Phone: 540-779-4918
  • Fax:
Mailing address:
  • Phone: 540-779-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024198159
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: