Healthcare Provider Details

I. General information

NPI: 1003599200
Provider Name (Legal Business Name): DIANE MARTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR. 5TH FLOOR
FAIRFAX VA
22031
US

IV. Provider business mailing address

8081 INNOVATION PARK DR. 5TH FLOOR
FAIRFAX VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-1646
  • Fax: 571-472-7037
Mailing address:
  • Phone: 571-472-1646
  • Fax: 571-472-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number0001229190
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number0001229190
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number0001229190
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: