Healthcare Provider Details

I. General information

NPI: 1356328413
Provider Name (Legal Business Name): DAWN C WYCKOFF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 FAIR LAKES PKWY
FAIRFAX VA
22033-3952
US

IV. Provider business mailing address

12255 FAIR LAKES PKWY
FAIRFAX VA
22033-3952
US

V. Phone/Fax

Practice location:
  • Phone: 808-321-1056
  • Fax:
Mailing address:
  • Phone: 808-321-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9832
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: