Healthcare Provider Details

I. General information

NPI: 1861225831
Provider Name (Legal Business Name): SOPHIA ANTWI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 SHIRLEY GATE RD
FAIRFAX VA
22030-5518
US

IV. Provider business mailing address

7936 BRESSINGHAM DR
FAIRFAX STATION VA
22039-3157
US

V. Phone/Fax

Practice location:
  • Phone: 703-205-9452
  • Fax: 703-653-1389
Mailing address:
  • Phone: 703-731-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0001150860
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: