Healthcare Provider Details

I. General information

NPI: 1174312391
Provider Name (Legal Business Name): SIMIN JIZAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 TARA DR
FAIRFAX VA
22032-2037
US

IV. Provider business mailing address

4707 TARA DR
FAIRFAX VA
22032-2037
US

V. Phone/Fax

Practice location:
  • Phone: 703-399-9903
  • Fax:
Mailing address:
  • Phone: 703-399-9903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number0001211119
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: