Healthcare Provider Details

I. General information

NPI: 1407201833
Provider Name (Legal Business Name): ANN ROCHELL ERMITANIO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

14989 GRASSY KNOLL CT
WOODBRIDGE VA
22193-6004
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4724
  • Fax: 571-472-0241
Mailing address:
  • Phone: 808-829-1527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number096
License Number StateMP
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007287
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008315
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: