Healthcare Provider Details

I. General information

NPI: 1548715154
Provider Name (Legal Business Name): MELISSA NICOLE WOMBLE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 11/27/2023
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 ARLINGTON BLVD
FAIRFAX VA
22031-4617
US

IV. Provider business mailing address

8501 ARLINGTON BLVD
FAIRFAX VA
22031-4617
US

V. Phone/Fax

Practice location:
  • Phone: 703-970-6458
  • Fax: 703-970-6465
Mailing address:
  • Phone: 703-970-6458
  • Fax: 703-970-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810005316
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: