Healthcare Provider Details

I. General information

NPI: 1750011714
Provider Name (Legal Business Name): OLIVE UWAMALIYA MSN APRN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13135 LEE JACKSON MEMORIAL HWY STE 135
FAIRFAX VA
22033-1907
US

IV. Provider business mailing address

13135 LEE JACKSON MEMORIAL HWY STE 135
FAIRFAX VA
22033-1907
US

V. Phone/Fax

Practice location:
  • Phone: 703-961-0488
  • Fax: 703-961-0480
Mailing address:
  • Phone: 703-961-0488
  • Fax: 703-961-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0024184457
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: