Healthcare Provider Details

I. General information

NPI: 1265897391
Provider Name (Legal Business Name): KEDEST GEBRESELASSIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16712 JEFFERSON DAVIS HWY
DUMFRIES VA
22026-2115
US

IV. Provider business mailing address

16712 JEFFERSON DAVIS HWY
DUMFRIES VA
22026-2115
US

V. Phone/Fax

Practice location:
  • Phone: 703-221-7467
  • Fax:
Mailing address:
  • Phone: 703-221-7467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024173128
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001200565
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173128
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: