Healthcare Provider Details

I. General information

NPI: 1083856629
Provider Name (Legal Business Name): MARJORIE GUERRERO CRUZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 WOLF RUN SHOALS RD
FAIRFAX STATION VA
22039-1742
US

IV. Provider business mailing address

6107 CLEARBROOK DR
SPRINGFIELD VA
22150-2411
US

V. Phone/Fax

Practice location:
  • Phone: 703-250-1944
  • Fax:
Mailing address:
  • Phone: 571-243-5486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number0001104501
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: