Healthcare Provider Details

I. General information

NPI: 1184945982
Provider Name (Legal Business Name): ANGELA PENNISI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 07/21/2022
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR FL 3
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-1660
  • Fax: 571-472-1661
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101266673
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-8784
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number0101266673
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberE-8784
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101266673
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: